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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,Yd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Far. (209)468-3433 Web:www.sjgov.org/chd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION"PORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request <br /> 0 rj <br /> Onsite Service Technician's Name: T CC Service Technician/Installer Certification#: Manufacturer Training: <br /> r? <br /> SERVICE SERVICE <br /> Leak detector <br /> F-1 mechanical Model: <br /> �L Spill bucket 0 minimum 5 gallon <br /> electronic Serial# Cl 0 1 hour hydrostatic 0 Incon TS-STS <br /> 21 *, 0 0 Caldwell System ❑0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: <br /> 0 line test roammed <br /> 0 Caldwell System 0 Other <br /> pgr <br /> . Leak detector <br /> 0 mechanical Model: Spill bucket 0 minimum 5 gallon <br /> ❑ 0 electronic Serial 1 hour hydrostatic 0 Incon TS-STS <br /> 0 line test programmed 0 Caldwell System 0 Other <br /> sensor❑ Primary piping testing at: <br /> 0 positive shutdown Model: 0 psi <br /> 0 fail safe Serial minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> 0 0 positive shutdown Model: 0 psi <br /> 0 fail safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary containment repairs for: <br /> ❑ 0 positive shutdown Model: ❑ LTDC(s) Piping <br /> 0 fail safe Serial#: Sump(s) UST(s) <br /> 0 NA <br /> 0 Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> Overfill❑ prevention(see LG letter 150-1) 'R Other: see below <br /> 0,j <br /> L yy <br /> As <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> EHD Inspector: I ReccLyOd By: ...... <br /> Title: <br /> -11)23-04 <br />