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0 SAN JOAQUIN COUNTY 6 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sieov.ory/ehd UNDERGROUND STORAGE TANK UST) PROGRAM SERVICE REQUEST INSPEC"1'10N REPORT' Facility Name: _ ❑ mechanical Model: Inspection Date: ( ❑ line test programmed Facility Address: Leak detector Service #• \ Request ❑ ❑ line test programmed Service Technician's Name: ICC Service Technician/[nstaller Certification #: Manufacturer Training: F,nite ❑ electronic Serial #: ❑ line test 2roEammed sensor ❑ ❑ positive shutdown Model: SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test 2roEammed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ 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) SERVICE >> -` Spill bucket '0 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 By: 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 EHD 23-04 �. aav OA/99/n7 THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector:Receiv By: EHD 23-04 �. aav OA/99/n7