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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />30?ast Weber Avenue, 3d Floor, Stockton, CA 952T-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />01jall and I 1U 1111(4 101 <br />Address: I <br />I/ t W96110 (� <br />Service Technician's Name: <br />Serblcel�equest #: <br />� M 5-61vh <br />ICC Service Technician/Installer Certification #: Manufacturer Training: <br />01 <br />I T— <br />F- SERVICE <br />SERVICE <br />Leak detector <br />El El mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />El Caldwell System 0 Other <br />Leak detector <br />❑ <br />El mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System 0 Other <br />0 line test programmed <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />0 1 hour hydrostatic El Incon TS -STS <br />0 mechanical Model: <br />❑ <br />0 electronic Serial <br />Primary piping testing at: <br />El line test programmed <br />psi <br />sensor <br />minutes <br />El positive shutdown Model: <br />Secondary piping testing at: <br />0 fail safe Serial <br />psi <br />0 NA <br />minutes <br />sensor <br />Secondary containment repairs for: <br />El positive shutdown Model: <br />❑ <br />0 fail safe Serial #: <br />Sump(s) UST(s) <br />El NA <br />Cold start of monitoring panel <br />sensor <br />Corrosion protection <br />El positive shutdown Model: <br />El <br />0 fail safe Serial <br />El NA <br />tube with mechanical overfill at 95% <br />VDrop <br />Drop tube with mechanical overfill at 95% <br />Elverfill <br />prevention (see LG letter 150-1) <br />EHD 23-04 <br />1/3/07 <br />Spill bucket 0 minimum 5 gallon <br />D <br />0 1 hour hydrostatic El Incon TS -STS <br />El Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />[I Caldwell System El 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 />[--]A <br />Cold start of monitoring panel <br />FA <br />Corrosion protection <br />11 <br />Other: see below <br />