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16 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN* <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> C <br /> m <br /> ility Nae: Inspection Date: <br /> Facility A dress: Service Request#: <br /> O� W041) 0�12°� <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: nufacturer Training: <br /> C�e cis Sas 4 e7 q VM& pyd;r <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 /> 0 ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> I ensor ,/ Primary piping testing at: <br /> ❑ positive shutdown Model: 2-4L� <br /> ❑ psi <br /> ❑ fail safe Serial#: <br /> El NA minutes <br /> -M WAip 10 sensor Secondary piping testing at: <br /> positi a shutdown Model: a+0� ❑ psi <br /> ❑ fail safe Serial #: `pOss minutes <br /> ❑ 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 /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> I I'l �SU►'� w I'lJV lv�-- <br /> `lA.>r� <br /> HIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> Et R e' ed By: Title: <br /> f 6 ��— QLA-\ <br /> EHD 23-04 <br /> Rev 06/22/07 , <br />