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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: ❑ ❑ mechanical Model: EHD [nspecto Facility Address: Title: Service Request #: 5 277 % ❑ Leak detector ❑ Onsite Service Technician's Name: ICC Servicrh ician/Instal^Certification #: Manufacturer Training: i� 4-36 � ?4b9 ❑ SERVICE Leak detector ❑ ❑ mechanical Model: EHD [nspecto ❑ electronic Serial #: Title: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: 77 ❑ electronic Serial #: ❑ line test programmed V4eutl,r sensor 033 1 ❑ ❑ positive shutdown Model: u— R minutes ❑ fail safe Serial #: ❑ ❑ NA 17 CD 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) 38 SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS EHD [nspecto ❑ Caldwell System ❑ Other Title: 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 a Primary piping testing at: 77 psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below a.. s w w•c n o V,c t �.-- �l� Sc..s� e��•• 1.� THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD [nspecto Received By: Title: FA EHD 23-04 Rev 06/22/07