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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephoner(209)468-3420 Fain(209)468-3433 Web:www.sihov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE R QUEST INSPECTION PORT <br /> Facility Name: Inspection Date: <br /> eV / <br /> Facility Address: Service Request#: <br /> c Jr t <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: a ufacturer Trainin <br /> ` � 2 !� rL <br /> ._. <br /> SERVICE SERVICE <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 2 )grammed <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: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 1:1 Caldwell System F-1 Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> El fail safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) 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% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> Oma-- <br /> THIS FACILITY IS SU JECT TO REINSPECTION AT ANY TIME AT1EH9,!S.,CURE T HOURLY RATE. - <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />