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SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMENT• <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Weh: www -cion., nrn/e>„I <br />UNDERGROUND STORAGE TANK S PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />�S1 Ga <br />Facility Address: 21 log <br />Service Request #: <br />.2+0DiglltEc sT �c.9 Kflosvoi <br />Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />2walumA levy 5Z-7555-1 - u 1 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test prowarnmed <br />�..- �: �y ► <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfillat 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Ell <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />El Primary <br />minutes <br />Secondary piping testing at: <br />❑ psi <br />minutes <br />Secondary containment repairs for: <br />❑ UDC(s) Piping <br />Sump(s) UST(s) ' <br />❑ Cold start of monitoring panel <br />❑ Corrosion protection <br />® Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />j <br />r <br />t .v <br />rTY <br />�..- �: �y ► <br />HIS IS SUB <br />EHD 23-04 <br />Rev 06/22/07 <br />j <br />