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SAN JOAQUIN COUNTY is <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:wwwsjgov-oreh <br /> UNDERGROUND STORAGE TANK LUST) PROGRAM SERVICE RE2UEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> A <br /> Facility Address: Service Request#: <br /> A <br /> Gas <br /> q <br /> Technician's Name: aller Certification#: Manufacturer Training <br /> —I;A= , !�� <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: 0 0 1 hour hydrostatic 11 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System El Other <br /> F-1 line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 11 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> D electronic Serial <br /> El line test roammed <br /> 0 Caldwell System 0 Other <br /> pE <br /> . Leak detector Spill bucket El minimum 5 gallon <br /> 0 mechanical Model: 0 0 1 hour hydrostatic El Incon TS-STS <br /> ❑0 electronic Serial #: D Caldwell System 0 Other <br /> line test proEammed <br /> sensor <br /> D 0 positive shutdown Model: Primary piping testing at: <br /> psi <br /> 0 fail safe Serial [F-1 <br /> El NA minutes <br /> sensor Secondary piping testing at: <br /> El 0 positive shutdown Model: ❑ psi <br /> El fail safe Serial#: minutes <br /> DNA <br /> sensor Secondary containment repairs for: <br /> El 0 positive shutdown Model: El UDC(s) Piping <br /> 13 fail safe Serial #: <br /> DNA Sump(s) UST(s) <br /> I <br /> El Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> 0 Drop tube with mechanical overfill at 95% 01 Corrosion protection <br /> L 0 L Overfill prevention(see LG letter 150-1) 39 Other: see below <br /> V X23 Lk *'YLWZ, tqKikf, <br /> LtiA I 5M <br /> I <br /> TS FACT 4TY IS SUBJrd'rTO RINSPECTION AT ANY TIRAEAT EH 'S CURRENT HOURLY RATE. <br /> E Ippic 1:111 11111 AA I Rece ed By: Title: <br /> V V <br /> EHD 21- 4 <br /> Rev 06/22/07 <br />