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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: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST I PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Name: Inspection Date: <br />OWI VMV a� qUV3L M. <br />Onsite Service Technician's Name: [CC Service Technician/Installer Certification #: Manufacturer Tr,,*,',n,: <br />\) �_ <br />SERVICE <br />Spill bucket F-1 minimum 5 gallon <br />Leak detector <br />M <br />0 mechanical Model: <br />Spill bucket 0 minimum 5 gallon <br />El electronic Serial <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 line test 2roffammed <br />0 Caldwell System 0 Other <br />Leak detector <br />❑ <br />0 mechanical Model: <br />D I hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial <br />El Caldwell System 0 Other <br />0 line test proFammed <br />Primary piping testing at: <br />. Leak detector <br />❑ <br />0 mechanical Model: <br />minutes <br />0 electronic Serial #: <br />Secondary piping testing at: <br />❑ line test programmed <br />psi <br />sensor <br />❑ <br />0 positive shutdown Model: <br />Secondary containment repairs for: <br />0 fail safe Serial <br />UDC(s) Piping <br />F-1 NA <br />Sumps) UST(s) <br />sensor <br />Cold start of monitoring panel <br />0 positive shutdown Model: <br />Corrosion protection 0 <br />M fail safe Serial <br />Other: see below5AN-T--/5F&D <br />DNA <br />sensor <br />0 positive shutdown Model: <br />0 fail safe Serial <br />DNA <br />F-1 <br />Drop tube with mechanical overfill at 95% <br />0 <br />Drop tube with mechanical overfill at 95% <br />L- 0 <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket F-1 minimum 5 gallon <br />0 El I hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />- Spill bucket 13 minimum 5 gallon <br />0 <br />D I hour hydrostatic 0 Incon TS -STS <br />El 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 />R <br />Cold start of monitoring panel <br />0 <br />Corrosion protection 0 <br />T <br />Other: see below5AN-T--/5F&D <br />Mal <br />EHD 23-04 <br />Rev 06t22/07 <br />Z%if I -Rip <br />W fid, "M <br />I"F,,Y TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspect <br />EHD 23-04 <br />Rev 06t22/07 <br />