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OF SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org UNDERGROUND STORAGE TANK UST PROGRAM SERVICE RE UEST INSPECTION REPORT Facility Name: Inspection D te: !e Technician's me: ICC Service Technician/installer Certification #: Manufacturer Training: � 1, EHD 23-04 RPv nA/*29/07 SERVICE Leak detector ❑ ❑ mechanical Model: ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ electronic Serial #: ❑ Caldwell System ❑ Other ❑ line test proyarruned Spill bucket ❑ minimum 5 gallon Leak detector ❑ ❑ mechanical Model: ❑ Caldwell System ❑ Other ❑ electronic Serial #: Spill bucket ❑ minimum 5 gallon ❑ line test proEammed ❑ 1 hour hydrostatic ❑ Incon TS -STS Leak detector ® ❑ mechanical Model: Primary piping testing at: ❑ electronic Serial #: psi ❑ line test proEammed minutes sensor ® ❑ positive shutdown Model: psi ❑ fail safe Serial #: minutes ❑ NA Secondary containment repairs for: sensor ❑ ❑ positive shutdown Model: Sump(s) UST(s) ❑ fail safe Serial #: Cold start of monitoring panel ❑ NA Corrosion protection 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) EHD 23-04 RPv nA/*29/07 SERVICE 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 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: ❑ UDC(s) Piping Sump(s) UST(s) Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below IM - 0 e .- r