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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />W <br />-302 <br />600 East Main Street, Stockton, CA 95202 9 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPO] <br />i� <br />I L, <br />imam <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />■ <br />Leak detector <br />0 mechanical Model: <br />EHD Inspector: <br />0 electronic Serial #: <br />■ <br />0 line test ••• -. <br />Leak detecto■r, <br />I <br />n mechanical Model: <br />ii <br />0 electronic Serial #: <br />0 line test programmed <br />Leak detector <br />0 mechanical Model: <br />0 electronic Serial #: <br />0 line test prowarrimed <br />sensor <br />0 positive shutdown Model: <br />1 0 fail safe Serial #: <br />0 NA <br />sensor <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0- NA <br />sensor <br />0 positive shutdown Model: <br />01fail safe Serial #: <br />0 NA <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />-liection Date: <br />41171,12— <br />ILA I VZO069:L69 <br />ifinstaller Exp. Date: I Manufacturer Training* <br />SERVICE <br />EH® 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />Spill bucket El minimum 5 gallon <br />■ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />EHD Inspector: <br />Spill bucket El minimum 5 gallon <br />■ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />01 Caldwell System 0 Othe■ r <br />Spill bucket 0 minimum 5 gallon <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />,t due by: <br />Testing for the above components are nex <br />Note: Please be aware that 2* containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />lons <br />Corrosion protection <br />Other: see below <br />EH® 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />WA <br />EHD Inspector: <br />EH® 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />