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a :SAN JOAQUIN COUNTY *4WENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web: www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT" <br /> Facility Name: Inspection Date: <br /> iv qtr~ 4+- ( 'i--© 9 <br /> Facility Address. Service Request#: <br /> Z+ZFso c,C-IC-( -k+, �Q()d s6 9 s <br /> Onsite Service Technician's Name: ICC service Tech niclan/Instalier Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ 11 mechanical Model: ❑ ❑ 1 hour hydrostatic Q Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> Q line test prograrnmed <br /> Leak detector Spill bucket Q minimum 5 gallon <br /> F-1 ❑ mechanical Model: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line testroammed <br /> ❑ Caldwell System El Other <br /> Leak detector Spill bucket Q minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ El hour hydrostatic D Incon TS-STS <br /> ❑ electronic Serial #: <br /> Q line test programmed 13 Caldwell System ❑ Other <br /> sensor 1�s� <br /> D positive shutdown Model: Primary piping tes ing at: <br /> 1] Q fail safe Serial #: '54::) psi <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> Q ❑ fail safe Serial #: El psi <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ Q positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> Q Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% Q Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Q Other: see below <br /> �^c� c.K �c, ,,,� it I►/.., o <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME A EHD'S CURRE14T HOURLY RATE. �. <br /> EMD inspector: Received By: Title: <br /> EHD 23-04 <br /> Rev 06122/07 <br />