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SAN JOAQUIN COUNTY is <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax.- (209) 468-3433 Web: www.sigoy.org�e <br />UNDERGROUND STORAGE TANK UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fa Uit <br />CMName: Inspection D e: <br />AMAAW P. -I <br />40W V <br />Onsite Service Technician's Name: ICC Service Technician/installer Certification #: <br />1�� <br />Leak detecto■ r <br />0 mechanical Model: <br />0 electronic Serial <br />0 line test programmed <br />Leak detector <br />■ <br />F-1 mechanical Model: <br />F-1 electronic Serial #: <br />0 line test programmed <br />Leak detecto■ r <br />0 mechanical Model: <br />0 electronic Serial #: <br />El line test programmed <br />senso■ r <br />0 positive shutdown Model: <br />F-1 fail safe Serial #: <br />DNA <br />sensor <br />0 positive shutdown Model: <br />1:1 fail safe Serial #: <br />El NA <br />senso■ r <br />11 positive shutdown Model: <br />0 fail safe Serial <br />El NA <br />Drop tube with mechanical overfill at 95% <br />El I Overfill prevention (see LG letter 150-1) <br />I <br />EHD 23-04 <br />Rev 06/22/07 <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon. TS -STS <br />0 Caldwell System ❑ Other <br />Spill bucket El minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />- Spill bucket 11 minimum 5 gallon <br />F-1 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />0 <br />UDC(s) Piping <br />Sump(s) UST(s) <br />0 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />Other: see below <br />I <br />EHD 23-04 <br />Rev 06/22/07 <br />