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SAN JOAQUIN COUNTY <br /> 46 ENVIRONMENTAL HEALTH DEPARTME <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sit;ov.or ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na : Inspection Da, <br /> Facility Addr ss: Service Request#: <br /> Onsite.Se ce I echnici ame: ICC Service Technician/installer Certification#: Manufacture Training: <br /> SER ! �.�� SERVICE a <br /> Leak detector 'i <br /> El mechanical Model: (Sl 41 Spill bucket minimum 5 gallon <br /> ❑ El electronic Serial #: 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed Caldwell System ❑ Other <br /> Leak detector t ��,-.Spill bucket K minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial #: � ❑ 1 hour hydrostatic El Incon TS„STNS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector ii <br /> ❑ mechanical Model: JI Spill bucket �9 minimum 5 gallon <br /> ❑ f 1 hour hydrostatic ❑ Incon TS-ST <br /> ❑ electronic Serial #: ❑ Caldwell System El Other <br /> ❑ line test ro ammed 1 <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> \ t AiK ,�v <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect R�ei� y: Title: <br /> 4- <br /> EHD 23-04 <br /> Rev 06/22/07 <br />