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• SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.ore/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:, Inspection Date: <br /> 1- <br /> Facility Address: q Service Request#: <br /> Onsite Service Tech 'clads Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> � - � - 0 2- Y- 09 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor 1NN -4+ ' <br /> ❑ positive shutdown Model: f-1 i 8 --m-Ac-AC Primary piping testing at: <br /> ❑ fail safe Serial #: 7'? �JJ�3 ❑ psi <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ <br /> El fail safe Serial #: El Secondary <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary containment repairs for: <br /> ❑ ❑ fail safe Serial#: ❑ UDC(s) Piping <br /> ❑ NA Sump(s) UST(s) <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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. - ived By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />