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is <br />SAN JOAQUIN COUNTY It <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjog v.or ehd <br />UNDERGROUND STORAGE TANK JUSTJ PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facilit Address: Service Request #: <br />qL L4 <br />Onsite Service Technician's Name: ICC Service Technician/installer Certification #: Manufacturer Training: <br />j <br />SERVICE <br />H <br />0 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ electronic Serial #: <br />❑ Caldwell System ❑ Other <br />❑ line test proEammed <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test projEammed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ Caldwell System ❑ Other <br />❑ mechanical Model: <br />Primary piping testing at: <br />❑ electronic Serial #: <br />psi <br />❑ line test 2rolEammed <br />minutes <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />psi <br />❑ fail safe Serial #: <br />minutes <br />❑ NA <br />Secondary containment repairs for: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Sump(s) UST(s) <br />❑ fail safe Serial #: <br />Cold start of monitoring panel <br />❑ NA <br />Corrosion protection <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 />H <br />0 <br />SERVICE <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 />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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />LEOther: <br />see below <br />I THtI FACILITY IS SUBJECT TO REINSP TION AT ANY TIME AT EHD's CURRENT HOURLY RATE. I <br />I EHD Insnect0 — 1 R eived v: I Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />