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SAN JOAQUIN COUNTY ` ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sj_gg_y.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facilit Na e: Leak detector Inspection Date: Facilit Address: /nis �, ❑ electronic Serial #: ervice Request #: Onsite Service Technician's Name: Gwk LWO-k �- ICC Service Technician/Installer Certill tion #: o ', v Manufacturer Training: �a�l q OP ► CP SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: H I torl ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor V Model: ❑ positive shutdown 7 `rNail safe Serial #: —�� A ❑ sensor positive shutdown Model: ❑ fail safe Serial #: -7 ❑ NA ❑ 5TP sensor positive shutdown Model: fail safe Serial #7 1 ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other H I torl 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 Rev 06/22/07 Die so✓ >J�54vt 1 S Ow✓► , s �THIB FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. H I torl Received By/Title: a e/Mj 5 C orriAl/5 EHD 23-04 Rev 06/22/07