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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: ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />c(ol"e., b/17A>2� <br />Facility Address: Service kle-q—.. 6—t —#. <br />Service Technician's Name: ICC Service Technician/installer Certification #: Manufacturer Training: <br />I SERVICE i <br />SERVICE <br />Leak detecto■ r <br />Spill bucket El minimum 5 gallon <br />0 mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial <br />0 Caldwell System 0 Other <br />El line test programmed <br />— Spill bucket 1:1 minimum 5 gallon <br />Leak detecto■r <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 mechanical Model: <br />11 Caldwell System 0 Other <br />0 electronic Serial <br />— Spill bucket El minimum 5 gallon <br />11 line test programmed <br />El I hour hydrostatic 0 Incon TS -STS <br />Leak detecto■ r <br />0 Caldwell System 0 Other <br />0 mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial <br />psi <br />0 line test programmed <br />minutes <br />senso■ r <br />Secondary piping testing at: <br />0 positive shutdown Model: <br />-5— psi <br />r-1 fail safe Serial #: <br />minutes <br />El NA <br />Secondary containment repairs for: <br />sensor <br />UDC(s) Piping <br />0 positive shutdown Model: <br />Sump(s) UST(s) <br />0 fail safe Serial #: <br />Cold start of monitoring panel <br />R NA <br />Corrosion protection <br />sensor <br />Other: see below <br />El positive shutdown Model: <br />0 fail safe Serial #: <br />El NA <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />i Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />— Spill bucket 1:1 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />:44 10 1--1 U 40 g [1111 J, I a <br />11 Caldwell System 0 Other <br />— Spill bucket El minimum 5 gallon <br />0 <br />El I hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />El <br />psi <br />minutes <br />Secondary piping testing at: <br />-5— psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />F-1 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />0 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />For'; <br />:44 10 1--1 U 40 g [1111 J, I a <br />EHD Inspector: <br />A <br />EHD 23-04 <br />Rev 06/22/07 <br />