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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.sigov.org/ehd <br />UNDERGROUND STORAGE TANK LUST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Address: <br />'2 <br />131 VA <br />Ompte Servic Techni #n's Name: ICC Service Technician/installer <br />SERVICE <br />_Wll � <br />= Service Request #: <br />& <br />tifiCdon #: Manufacturer Training: <br />1 VIS <br />IO e— A Z3 46 <br />SERVICE <br />Leak detecto■ r <br />0 El I hour hydrostatic M Incon TS -STS <br />El mechanical Model: <br />El electronic Serial #: <br />El <br />0 line test programmed <br />Leak detecto■ r <br />,, <br />Received <br />0 mechanical Model: <br />0 <br />0 electronic Serial #: <br />El line test programmed <br />Leak detecto■r <br />❑ <br />0 mechanical Model: <br />0 electronic Serial <br />El line test programmed <br />El <br />senso■ r <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 <br />0 NA <br />se., ' i FS 7007 <br />19 4"39V <br />0 <br />Xpositive shutdown Model: <br />0 <br />fail safe Serial #001 <br />0 <br />DNA <br />sensor <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 NA <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />_Wll � <br />= Service Request #: <br />& <br />tifiCdon #: Manufacturer Training: <br />1 VIS <br />IO e— A Z3 46 <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />0 El I hour hydrostatic M Incon TS -STS <br />0 Caldwell System E] Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />D I hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />,, <br />Received <br />— Spill bucket El minimum 5 gallon <br />0 <br />1:1 1 hour hydrostatic D 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 />El <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 />0 <br />Other: see below <br />IN <br />Wig I F, AW A =1 <br />�,L.AWWWN= <br />4 1 z M a tot nol 4-11111:9t <br />7 <br />1r'uii' <br />,, <br />Received <br />I EHD 23-04 - <br />Rev 06/22/07 <br />