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• SAN JOAQUIN COUNTY i <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 ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> Facility Address: Service Request#: <br /> S�2oor 321 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed <br /> ❑ Caldwell System E] Other <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: El 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> El NA minutes <br /> sensor Secondary piping testing at: <br /> Elpositive shutdown Model: <br /> ❑ <br /> El fail safe Serial #: ❑ psi <br /> El NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ positive shutdown Model: ( ) Piping <br /> ❑ ❑❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% El Corrosion protection <br /> 110:1 <br /> Overfill prevention(see LG letter 150-1) Other: see below <br /> fej-ml - PJo TS <br /> mg <br /> n tib f�1AJA <br /> Icis <br /> �.. f h !v►r�- W, to J. <br /> THIS FACILITY IS SU13JECT TO REINSPECTION AT ANY TIME AT f HD'S CURRENT HOURLY RATE. v <br /> EA Inspector: Received By: Title: <br /> T4A vC ©w'1'ti 61 <br /> EHD 23-04 <br /> Rev 06/22/07 <br />