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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENJ <br />'IV <br />00 East Main Street, Stockton, CA 95202-3029' <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: ww ' ow.sehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE R QUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Address: Service Request #: <br />2-:? q - <br />Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />SERVICE <br />Leak detector <br />- Spill bucket 0 minimum 5 gallon <br />F-1 mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial <br />0 Caldwell System 0 Other <br />El line test proEarnmed <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />❑ <br />0 mechanical Model: <br />0 Caldwell System F-1 Other <br />0 electronic Serial #: <br />- Spill bucket 0 minimum 5 gallon <br />0 line test programmed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />Leak detector <br />El Caldwell System 0 Other <br />El mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial <br />psi <br />El line test programmed <br />minutes <br />c1l -Ci ltj�T sensor <br />Secondary piping testing at: <br />El positive shutdown Model: 2�- <br />psi <br />F1 fail safe Serial <br />minutes <br />0 NA <br />Secondary containment repairs for: <br />sensor <br />El <br />0 positive shutdown Model: <br />Sump(s) UST(s) <br />0 fail safe Serial <br />Cold start of monitoring panel <br />0 NA <br />Corrosion protection <br />sensor <br />❑ <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 NA <br />El <br />Drop tube with mechanical overfill at 95% <br />ED <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />- Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPE3eTION VaT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />0 Caldwell System 0 Other <br />Rec(ved By: <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System F-1 Other <br />- Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />Primary piping testing at: <br />El <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 />0 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />0 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />THIS FACILITY IS SUBJECT TO REINSPE3eTION VaT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: I I <br />Rec(ved By: <br />Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />