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SAN JOAQUIN COUNTY V ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.or ehd UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: inspecti n Date: ,) -7• G/ —7 Facility Addres �. Or 9T Service Re uest #: y—o�5;�Se6�7 Onsite Service Technician's Name: / ICC Service Technician/installer Certification #: Manufacturer Training: SERVICE Leak detector ❑ ❑ mechanical Model: (Y ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ . ❑ line test programmed . Leak detector 1� mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ cWensor ❑ positive shutdown Model: ❑ fail safe Serial #: o`tel ❑ NA y P Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE bucket j�minimum 5 pill gallon r hydrostatic ❑Incon TS -STS TOCaldwell (Y System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CU RENT HOURLY RATE. ❑ 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 Rev 06/22/07 (Y IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CU RENT HOURLY RATE. *aTHISF�AqILITYr R�eivedBy: -� Title: EHD 23-04 Rev 06/22/07