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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEIv C <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.or ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac'lity Name: Ins a tion ate: <br /> Nil,( a v� <br /> Facility ddress: Service Request#: <br /> Onsite Service--Ti echnicia 's Name: ICC Service Technician/installer Certif ation#: nn� ctu er Training: ? <br /> SERVICE SERVICE <br /> Leak detector "� l��qq� Spill bucket minimum 5 gallon <br /> El mechanical Model: CIP P 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector SI pill bucket tFminimum 5 gallon <br /> ❑ mechanical Model: <br /> El <br /> 1:1 electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ Elpositive shutdown Model: ❑ UDC(s) Piping <br /> 11 fail safe Serial #: ( ) p g <br /> ❑ NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) they: see below <br /> s� <br /> THIP FA ILITY IS SUBJ CT TO REINSPE TION AT ANY T19E AT EHD'S CUR NT URLY RATE. <br /> Hs ect Received By: Tide: <br /> Pt I Cot �V11 —� <br /> EHD 23-04 <br /> Rev 06/22/07 <br />