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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.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />�fllp 01 1 b +0 11/1101 <br />Facility Address: Servici Reqhest b: <br />Onsite Service Technician's Nitme: ICC Service Technician/Installer Certification #: Man factuFrr Tlainin& <br />1 <br />0- 0 <br />lot <br />SERVICE <br />Leak detector <br />Spill bucket 0 minimum 5 gallon <br />EVmechanical Model: qmf is qA# <br />El I hour hydrostatic El Incon TS -STS <br />El electronic Serial #: yVjQjo%V <br />0 Caldwell System El Other <br />El line test programmed <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 mechanical Model: <br />El Caldwell System 0 Other <br />0 electronic Serial #: <br />- Spill bucket El minimum 5 gallon <br />F-1 line test programmed <br />0 1 hour hydrostatic 0 Incon. TS -STS <br />. Leak detector <br />El Caldwell System E] Other <br />F-1 mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial #: <br />psi <br />0 line test proEammed <br />minutes <br />sensor <br />Secondary piping testing at: <br />0 positive shutdown Model: <br />psi <br />0 fail safe Serial #: <br />minutes <br />El NA <br />Secondary containment repairs for: <br />sensor <br />F-1 <br />0 positive shutdown Model: <br />Sump(s) UST(s) <br />El fail safe Serial #: <br />Cold start of monitoring panel <br />El NA <br />Corrosion protection <br />sensor <br />R <br />0 positive shutdown Model: <br />El fail safe Serial #: <br />0 NA <br />R <br />- Drop tube with mechanical overfill at 95% <br />F-1 <br />_ Drop tube with mechanical overfill at 95% <br />L 0 <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />RIT (BKY�l <br />Spill bucket 0 minimum 5 gallon <br />El <br />El I hour hydrostatic El Incon TS -STS <br />0 Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />F-1 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El 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 E] Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />F-1 <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 />R <br />Corrosion protection <br />0 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />"00- <br />00�� <br />RIT (BKY�l <br />W., <br />�077MIMPM <br />EHD Ins ector: <br />EHD 23-04 <br />Rev 06/22/07 <br />"00- <br />00�� <br />