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4" v� THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD inspector.` Receiv By: i Title: EHD 23-04 Leak detector ❑ ❑ mechanical Model: SAN JOAQUIN COUNTY ❑ line test proEammed ENVIRONMENTAL HEALTH DEPARTMENT Leak detector ® 600 East Main Street, Stockton, CA 95202-3029 ❑ electronic Serial #: ❑ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si o� v.or /� ehd UNDERGROUND STORAGE TANK ST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: ❑ electronic Serial #: Inspection Rate: I ❑ line test 2rogMmed Facility Address: sensor Service Request #: ❑ positive shutdown Model: Onsite Service Technician's Name: [CC Service ITechniciantinstaller Certification #: Manufacturer Ttaineng- ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑NA. ❑ 4" v� THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD inspector.` Receiv By: i Title: EHD 23-04 Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test proEammed ❑ Leak detector ® ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test progammed Leak detector ® ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test 2rogMmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑NA. ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) 4" v� THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD inspector.` Receiv By: i Title: EHD 23-04 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sumps) UST(s) Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below 4" v� THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD inspector.` Receiv By: i Title: EHD 23-04