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r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj-goy.org-/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fc'pity N e: Inspection Date: <br /> W6-0 4-- /�/- a�, <br /> F ci ity A dre s: Service Request#: <br /> nsite S/e� c/e�t�T�echnici n's IC rvice Tec ician/Installer Certification#: Mnufact�ureer�Traai�ningg: <br /> V,91 <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 programmed <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 #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> E] fail safe Serial#: <br /> minutes <br /> El NA <br /> sensor <br /> El shutdown Model: Secondary piping testing at: <br /> ❑ E] psi <br /> El fail safe Serial #: <br /> minutes <br /> El NA <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 /> L <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> *-4d <br /> TH S F CILITY IS SUBJECT TO REINSPECTIOV yr ANA TI AT EHD'S CURRENT HOURLY RATE. <br /> �Hnp V ;7 1R 4 kZZ Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />