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AIL <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEP <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org <br /> UNDERGROUND G TAN (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Mame: Inspection Date: <br /> Facility Address: Service Request#: <br /> b ` , . <br /> Onsite SarvieckTec ni ian's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: - <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 proEammed <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 pro ammed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdownModel: ❑ si <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ 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 /> } <br /> i <br /> a <br /> HIS FACILITY IS SUBJECT T REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH tor: eived By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />