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SAN JOAQUIN COUNTY <br /> ANVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.or /g ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REP RT <br /> KF%ce: _ Inspection Date: <br /> rest/ Service Reques #: <br /> Wb Ck <br /> ce Technician's Name: ICC Service Technician/Installer Certification#: Ma ufacturer/7'* <br /> r ' ing: <br /> [.1 AF� <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 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 /> Spill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ mechanical Model. <br /> ❑ ❑ electronic Serial ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test ro ammed El Caldwell System ❑ Other <br /> sensor PZsi <br /> piping testi g of 3 UO�IV1 3 m <br /> ❑ ❑ positive shutdown Model: 5 � <br /> ❑ fall safe Serial#: L p <br /> I <br /> El NA ANK -m-hmtes ma <br /> sensor Secondary pipping testing at: �� uo <br /> F1positive shutdown Model: (Gl"J psi�j'� p <br /> ❑ fail safe Serial#: <br /> minufes Ma5? �� <br /> ❑ NA i-L 1 CY17rv— ;O <br /> sensor Akl 7t/ <br /> ❑ positive shutdown Model: Secondary con i nt •epairs or: <br /> ❑ ❑ UDC(s) Piping <br /> i ❑ fail safe Serial #: <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 /> �► q . <br /> �w- <br /> BUM <br /> S � <br /> 1 wY1 ash <br /> T IS F,$CILITY IS SUBJECT TO REtNSfPFCTION At ANY TIME AT EI-IDIS CURRENT HOURLY RATE. <br /> E D s t r: ey: Title: <br /> EHD 23-04 I 1 1 .... S{ C�An' 'f QM�6oAfy �v�n���/� ZTY ac( 't� r,%V-xd- I" <br /> Rev 06/22/07 09 �1'� a�I,IL l/l no t►twr Y` lQ� ��( Vv✓ ��t� d l� �v �� <br />