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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.sijgov.org-/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> LI-161 Tom- `5Aaos66-7 <br /> Onsite Service Technician's Name: CC Service Technician/installer Certification#: Manufacturer Training: <br /> Lug I x- 1 / NIA <br /> SERVICE SERVICE <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 /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> E3 electronic Serial El El hour hydrostatic El Incon TS-STS <br /> 1:1 line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: /1 ;W,�,_ — (Z: 5' <br /> ❑ ❑ ail safe Serial #: ElS�O psi 114 ��1 q� 4 dt�3d <br /> ❑ NA �aQ minutessensor <br /> Secondary piping testing at: `0`7 (47 <br /> ❑ positive shutdown Model: <br /> ❑ ❑ fail safe Serial #: ❑ psi <br /> minutes <br /> ❑ NA <br /> sensor <br /> Secondary containment repairs for: <br /> ❑ positive shutdown Model: <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 P,4,., G(D G <br /> to, td, 4"4- o,-, u 0 G A&-k jidsej <br /> a� U G- <br /> THIS FACILITY IS SUBJECT TO REINSPE AT Ato TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD lnsp R Title: <br /> EH D 23-0 <br /> Rev 06/22/07 <br />