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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />to X <br />-3029 <br />600 East Main Street, Stockton, CA 95202 <br />(209) 468-3433 Web: www.sigov.or <br />Telephone: (209) 468-3420 Fax. -q/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Addtess: Service Request#: <br />Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp. Date: <br />—7 <br />SERVICE SERVICE _71 <br />i--- <br />---- 0 <br />Leak detector — <br />■ <br />0 mechanical Mode■l: E <br />1 <br />0 electronic Serial #: <br />0 line test programmed <br />Leak detector <br />0 mechanical Model: <br />0 electronic Serial <br />■ <br />0 line test programmed <br />Leak detector <br />0 mechanical Model: <br />0 electronic . Serial <br />0 line test programmed <br />—1 <br />sensor <br />4- <br />0 positive shutdown Model: NEW <br />0 fail safe Serial #: <br />■ <br />v,_4 1 A <br />sensor <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 NA <br />Drop tube with mechanical overfill at 9t. <br />5% <br />Overfill prevention (see LG letter 150-1) <br />FM <br />I <br />9-3219ACUT I Moo NW&I"* <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />Spill bucket 0 minimum 5 gallon <br />■ <br />El 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System n Other <br />Spill bucket 0 minimum 5 gallon <br />0 1 hour hydrostatic 0 Incon TS -STS <br />i 0 Caldwell System 0 •t er <br />Spill bucket 0 minimum 5 gallon <br />■ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Secondary containment testing for: <br />LIDC(s) Piping <br />Sump(s) LIST(s) <br />■ <br />Testing for the above components are next due by: <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 />Corrosion protection <br />Other: see below <br />9-3219ACUT I Moo NW&I"* <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />