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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEO <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax.- (209) 468-3433 Web: www.sjgoy.org�eh <br />UNDERGROUND STORAGE TANK LUST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facilir Nap <br />\ Inspection Date: <br />Facility Ad_d�ess: Service Request #: <br />0 <br />5e <br />CD��n <br />QeOnsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />932M <br />SEfiACE <br />Leak dete■ ctor <br />0 0 1 hour hydrostatic 0 Incon TS -STS <br />n mechanical Model: <br />E] electronic Serial #: <br />❑ <br />Elline te "trogrammed <br />Leak detector <br />■ <br />El mechanical Model: <br />❑ <br />0 electronic Serial #: <br />El line test programmed <br />Leak detecto■ r <br />❑ <br />0 mechanical Model: <br />n electronic Serial #: <br />F■ -1 line test programmed <br />❑ <br />sensor <br />0 positive shutdown Model: <br />0 fail safe Serial <br />❑ <br />0 NA <br />-sensor <br />■ <br />0 positive shutdown Model: <br />0 <br />El fail safe Serial #: <br />0 <br />El NA <br />sensor <br />El positive shutdown Model: <br />F-1 fail safe Serial #: <br />F-1 NA <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />SEfiACE <br />Spill bucket 0 minimum 5 gallon <br />0 0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 1:1 Other <br />- Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />- Spill bucket El minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />0 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />0 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />17 M qi, MMMMIMMI <br />EHD inspector <br />EHD 23-04 <br />Rev 06/22/07 <br />