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0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgoy.orjz/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Faci' Name: Inspctio Date: <br /> (K 1a <br /> e-7 <br /> Facility Address: Service Request#: <br /> 5l� w- (1� � � 0� �IZ <br /> •nsite Service Technician's Name: ICC Service Technician/installer Certification#: Manu c r r Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket 13 minimum 5 gallon <br /> F-1 ❑ electronic Serial #: 11 ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <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 1 hour hydrostatic El Incon TS-STS <br /> 13 Caldwell System ❑ Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> El NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> El ❑ fail safe Serial #: ❑ psi <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: <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) Other: see below <br /> dOA4 Wac riq uA� OJ -5 94 , - C& <br /> 14 os(o5 <br /> w� 31IVA <br /> THIS FA ILITY IS SUBJECT TO REINSPECTIONq 5aY. DIS CURRENT HOURLY RATE. <br /> ed Title: <br /> i,j., <br /> EHD 23-04 <br /> Rev 06/22/07 <br />