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0 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.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />o Foot <br />Z-- O <br />Facility Address:����� <br />Service{R�equest #: <br />/I <br />219312-0 N !iK ar�Cd <br />/ <br />5 R O%5&16 q <br />Onsite Service Technician's Name: <br />ICC Service echnician/Installer Certification #: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Pu -DS - to <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME A EHD'S CURRENT HOURLY RAT <br />❑ electronic Serial #: <br />Received By: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Pu -DS - to <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME A EHD'S CURRENT HOURLY RAT <br />❑ Caldwell System ❑ Other <br />Received By: <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ 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 />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />ff 1 <br />'/ <br />Pu -DS - to <br />HOC- � Imo-( <br />CQ <br />THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME A EHD'S CURRENT HOURLY RAT <br />EHD hispec �r&,xt— <br />Received By: <br />Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />