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SAN JOAQUIN COUNTY <br />INVIRONMENTAL 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 JUST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facitit Name: Inspection Date: <br />Nsk & <br />1W.A.H.t. AAA -.- <br />R, <br />I N ' <br />L,C61 CA <br />rvice Technician/Installer Certification #: <br />SERVICE <br />detector <br />leLeak <br />echanical Model: Wggili FX(V <br />0 <br />0 electronic Serial #: I <br />0 line test proyammed <br />0 Caldwell System 0 Other <br />Leak detector <br />❑ <br />0 mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System 0 Other <br />0 line test 2roEammed <br />Spill bucket 0 minimum 5 gallon <br />. Leak detector <br />❑ <br />0 mechanical Model: <br />0 Caldwell System 0 Other <br />0 electronic Serial #: <br />Primary piping testing at: <br />❑ line test 2rogrammed <br />psi <br />sensor <br />❑ <br />El positive shutdown Model: <br />Secondary piping testing at: <br />0 fail safe Serial #: <br />psi <br />El NA <br />minutes <br />sensor <br />❑ <br />El positive shutdown Model: <br />UDC(s) Piping <br />F-1 fail safe Serial #: <br />Sumps) UST(s) <br />1:1 NA <br />Cold start of monitoring panel <br />-sensor <br />❑ <br />0 positive shutdown Model: <br />Other: see below <br />F-1 fail safe Serial #: <br />DNA <br />0 <br />Drop tube with mechanical overfill at 95% <br />F1 <br />Drop tube with mechanical overfill at 95% <br />0 <br />Overfill prevention (see LG letter 150-1) <br />Graining: V y-"' '-V'- <br />117 <br />ff) <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />0 <br />D I hour hydrostatic 0 Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />0 Caldwell System 0 Other <br />NJ <br />Spill bucket El minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 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 />Sumps) UST(s) <br />El <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 />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />NJ <br />EHD 23-04 <br />Rev 06/22/07 <br />