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SAN JOAQUIN r t INTY <br /> ENVIRONMENTAL HEALTq C, PARTMENT <br /> 600 East Main Street, Stockton, r.A4n, 02-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgoy.or�hd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility N me: Inspection Date: <br /> A AV <br /> Facility Address: Service Request#: <br /> Onsite <br /> pService <br /> ATec ician's Name*. ICC Service Technician/installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <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 /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial El El hour hydrostatic ElIncon 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: V/+?d� <br /> ❑ ❑ positive shutdown Model: fo� psi } � <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA �ttvt H, S <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 /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ElDrop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> 1:1Overfill prevention (see LG letter 150-1) ElOther: see below <br /> nd <br /> r w r�Ca re S tit�.+� s1 <br /> rule W th ,c�'- is ' I#WWW4 -k--g . <br /> THIS FACILITY IS SUB CT TO REINSPECT N AT ANY TIME T E D'S CURR NT HOURLY RATE. <br /> EHIns or: R eiv y: Title: <br /> i Xt <br /> EHD 23-04 <br /> Rev 06/22/07 <br />