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SAN JOAQUIN COUNTY r' <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.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: p Inspection{Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: " <br /> ti i S t ' <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Ad Spill bucket t .,minimum 5 gallon <br /> El F1 electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket 11 minimum 5 gallon <br /> ❑ <br /> F1 electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> 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 El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> i sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: psi <br /> 11 11fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> El ❑ 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% Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below 4{X �;;,� <br /> ^J 1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: — Received By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />