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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202-2708 <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: Inspecti n Date: <br /> a I ty ddress: Ser ice Keq4est#: <br /> m <br /> Onsi ervice T chnician's Name: ICC Service Technician/Installer Certification#: :Manufacturer Trainin : <br /> �uu G Stiff D VLA-1 5K- bit, <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El electronic Serial ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> El positive shutdown Model: El si <br /> Primarp piping testing at: <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% E1.1/Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below <br /> tV o stn^ u <br /> S FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHDIS CURRENT HOURLY RATE. <br /> EInspec r: eived Title: <br /> G ^ <br /> EHD 23-04 <br /> 1/3/07 <br />