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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.sijzov.org <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name- Inspection Date: _ /}Q <br /> W14- <br /> Facility Address: Service Request#: <br /> t_*1 !S - S-S-S" <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufa turer Training: <br /> OW <br /> SERVICE SERVICE <br /> Leak detector <br /> F-1 mechanical Model: U I Spill bucket 4 minimum 5 gallon <br /> ❑ El 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed <br /> Caldwell System ❑ Other <br /> Leak detector <br /> �_ 0El mechanical Model: Spill bucket minimum 5 gallon <br /> ❑ � ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed <br /> Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> ❑ Caldwell System E] Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 1:1 fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ 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 /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />