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• SAN JOAQUIN COUNTY 0 <br />ENV[RONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.ortrlehd <br />UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUES'L <br />LNSFEC 440N Khr"K I. <br />Facility Name: + g <br />te. JJ� <br />Inspection7/'j <br />�f <br />J ru, -,V'l. <br />i1 <br />Facility Add ess: f J <br />Service Ri`quest #: <br />Onsite Service Technician's Name: <br />IC Service Techmcia Installer Certification #: <br />Manofacturer Training: <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />7A rznc <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />THIS FACILITY IS SUBJECT TO REIN <br />❑ NA <br />sensor <br />OQ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />l <br />NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />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 />/-'Z <br />7A rznc <br />Secondary�� testing at: <br />-Lt? P&V q -S <br />THIS FACILITY IS SUBJECT TO REIN <br />bD minutes <br />2 <br />Secondary containment rwairs for': <br />OQ <br />UDC(s) Piping <br />-%�•� Titi,: <br />{C, 1 ��C "C [f 1 <br />)ew b l,L vim UST(s) <br />l <br />p(s) t - , <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />7A rznc <br />THIS FACILITY IS SUBJECT TO REIN <br />PECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD ector:tv�,d <br />ri <br />l <br />By: _ <br />nom' <br />-%�•� Titi,: <br />{C, 1 ��C "C [f 1 <br />l <br />11v--v!i <br />EHD 23-04 <br />" ' <br />Rev 06/22/07 <br />