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SAN JOAQUIN COUNTY <br />*ENVIRONMENTAL HEALTH DEPARTMENTd <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date.. <br />Facility Address: Service equest b: <br />co5-3 -3-0 -3 <br />[Onsite Servicee��Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training:CVG �:— <br />S 4 "P 14,, <br />-T— oe—Xc, S � & I <br />� 3 <br />- -7' <br />SERVICE <br />SERVICE <br />Leak detecto■ r <br />Spill bucket 0 minimum 5 gallon <br />El mechanical Model: <br />0 1 hour hydrostatic El Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System El Other <br />El line test programmed <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />■ <br />■ mechanical Model: <br />0 Caldwell System ❑ Other <br />El electronic Serial #: <br />Spill bucket 0 minimum 5 gallon <br />El line test programmed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />Leak detecto■ r <br />0 Caldwell System 11 Other <br />El mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial #: <br />psi <br />R line test programmed <br />minutes <br />Secondary piping testing at: <br />psi <br />■ <br />0 minutes <br />Secondary containment repairs for: <br />sensor <br />UDC(s) Piping <br />• positive shutdown Model: <br />Sump(s) UST(s) <br />• fail safe Serial #: <br />Cold start of monitoring panel <br />DNA <br />Corrosion protection <br />sensor <br />Other: see below <br />0 positive shutdown Mode■ l: <br />0 fail safe Serial #: <br />DNA <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150- 1) <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic El Incon TS -STS <br />THIS FACILITY IS SUBJ&TTO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RAT <br />0 Caldwell System ❑ Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 11 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />psi <br />0 minutes <br />Secondary containment repairs for: <br />19 <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 />EHD 23-04 <br />Rev 06/22/07 <br />THIS FACILITY IS SUBJ&TTO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RAT <br />EHD 23-04 <br />Rev 06/22/07 <br />