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16 SAN JOAQUIN COUNTY 16 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgoy.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facili Name: <br />4 7' to r, r -oil <br />Inspection Pate, <br />Facility Address: <br />Service Ikequest #: <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />2-y%J C a d U <br />1 zooh <br />v w <br />SERVICE <br />VAI <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />�✓� <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />I�( <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />prop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />VAI <br />��pill bucket Vminimum 5 gallon <br />14 <br />❑ 1 hour hydrostatic 15Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />�✓� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Title: <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 />I�( <br />Cold start of monitoring panel Mail TeS 31 <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />s i <br />VAI <br />C �r� Sten ^v �fvl N e,t j <br />i� lguGtk- <br />4 <br />&4 DSI i 6t-/ � <br />G f o-^- <br />o <br />.5 /Z-( ac L <br />�✓� <br />THIS FACILITY IS SUBJECf TO REINSPECTION AT A -NY TIME AT END'S CURRENT HOURLY RATE. <br />EHD ector: <br />Receivedfiy: <br />Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />