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• SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 465-3420 Fax: (209) 468-3433 Web: www.sjgov.or <br />UNDERGROUND STORAGE TANK UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date <br />C�AeIL �r�� 17('10 <br />f.... _. ___. <br />Service Technician's Name: ICC Service Te hnici <br />►►n,tA,- NA o 4 e c r-\- t 11(4 e <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />El <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />line test programmed <br />,qLi�_ -sensor W uMir <br />❑ <br />positive shutdown Model: <br />9fail safe Serial #: <br />NA <br />❑ <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <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 />I- rl <br />L" <br />rAA I <br />THIS FACILITY IS SUBJECT <br />:star: <br />EHa 23-04 <br />Rev 06122107 <br />Service Request #: <br />, S/' o S <br />Certification #: Manufacturer Training: <br />VvOL <br />1,P1 <br />_-r i / e <br />SERVIC <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 />El <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 />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 />❑ <br />Other: see below <br />41-1 C19 P/R ff, <br />REINSPE& ION AT ANY TIME T EHD'S CURRENT HOURLY RATE. <br />re <br />t� <br />/A <br />