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0 SAN JOAQUIN COUNTY i ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sipov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name::" Inspection Date: Leak detector ❑ Facilit Address: Service R1quWt #: ❑ electronic Serial #: Q oo5633q Onsite Service Technician's Name: ICC Service Technician/installer Certification #: ManufacturerTrainln Uf, 'tel z�j • al—� o� ❑ oC- D ��F SERVICE so Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: or: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor El❑ positive shutdown 11fail 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) SERVICE so Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other or: 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 Sump(s) UST(s) :' Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below EHD 23-04 7'r f /-11 RRA M/99W so V 1 hiGF THI A 1 ITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S C RRENT HOURLY RATE EImp or: Recei Title: EHD 23-04 7'r f /-11 RRA M/99W