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SAN JOAQUIN COUNTY <br />ONVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax.- (209) 468-3433 Web: www.si2ov.org/ehd <br />UNDERGROUND STORAGE TANK tUST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />606M 0 K t Ck Sp14 6110(rg <br />Facility Address: Service Request #: <br />Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />530-7"(.—CtT- S457-t-.4 VJAVtf^'/S f/ P- ez,+ ve4,v� <br />I SERVICE i <br />SERVICE <br />Leak d■ etector <br />- Spill bucket 0 minimum 5 gallon <br />0 mechanical Model: <br />0 1 hour hydrostatic El Incon TS -STS <br />0 electronic Serial #: <br />El Caldwell System F-1 Other <br />El line test programmed <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />■ <br />■ mechanical Model: <br />0 Caldwell System 0 Other <br />■ electronic Serial #: <br />- Spill bucket El minimum 5 gallon <br />El line test p )grammed <br />El I hour hydrostatic 0 Incon TS -STS <br />F-- 7 <br />Leak detecto■ r <br />0 Caldwell System 0 Other <br />0 mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial #: <br />psi <br />El line test programmed <br />minutes <br />sensor <br />■ <br />D positive shutdown Model: <br />Psi <br />0 fail safe Serial #: <br />minutes <br />El NA <br />Secondary containment repairs for: <br />sensor <br />■ <br />0 positive shutdown Model: <br />Sump(s) UST(s) <br />0 fail safe Serial <br />Cold start of monitoring panel <br />El NA <br />Corrosion protection <br />sensor <br />Other: see below <br />0 positive shutdown Model: <br />El fail safe Serial #: <br />0 NA <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 />❑ <br />0 1 hour hydrostatic El Incon TS -STS <br />El Caldwell System F-1 Other <br />I EHD hispector. <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System 0 Other <br />- Spill bucket El minimum 5 gallon <br />0 <br />El I hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />Psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />19" <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />0 <br />Other: see below <br />�AAII Av <br />III 111111111 lill 11111�;111111 1111��Iijqi 111111111 1111111111111 .111 11 111 <br />I EHD hispector. <br />lax <br />EHD 23-04 <br />Rev 06/22/07 <br />