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0 SAN JOAQUIN COUNTY 40 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.ore chd UNDERGROUND STORAGE TANK UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facilitv Name- Inspection Date: Fa�Service Request �� nsit Service Technician's Name: ICC Service Technician/installer Certificati n #: ltanufactu r Training: SERVICE Spill bucket Xm1nimum 5 gallon Leak detector ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon ❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ line test programmed ❑ Caldwell System ❑ Other Leak detector ❑ ❑ mechanical Model: ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ electronic Serial #: ❑ Caldwell System ❑ Other ❑ line test programmed Primary piping testing at: Leak detector ❑ ❑ mechanical Model: minutes ❑ electronic Serial #: Secondary piping testing at: ❑ line test programmed psi sensor ❑ ❑ positive shutdown Model: Secondary containment repairs for: ❑ fail safe Serial #: UD C(s) — -- ------ ---- Piping ❑ NA Sump(s) – --_ -- UST(s) sensor ❑ ❑ positive shutdown Model: Corrosion protection ❑ fail safe Serial #: Other: see below ❑ NA _ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE Spill bucket Xm1nimum 5 gallon 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS . ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UD C(s) — -- ------ ---- Piping Sump(s) – --_ -- UST(s) ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ri/Ir2W / .' / � Ylr:rl /FA 1ANWN . EHD 23-04 Rev 06/22/07