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9 <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.si ov.or ehd <br />UNDERGROUND STORAGE TANK UST PROGRAM SERVICE RE2UEST INSPECTION REPORT <br />Facility Name: Inspection Date <br />(^ A 1✓ A VA ,All <br />Facility Address: Service Request #: <br />a6� I ?.,, I x 9). —>S , <br />Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />SERVICE <br />Spill bucket Kminimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Spill bucket ❑ minimum 5 gallon <br />❑ electronic Serial #: <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ line test proEammed <br />❑ Caldwell System ❑ Other <br />611- Leak detector <br />Spill bucket ❑ minimum 5 gallon <br />mechanical Model: I- - <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ electronic Serial #: C2902-11 °� <br />❑ Caldwell System ❑ Other <br />❑ line test 2rojEammed <br />Primary piping testing at: <br />Leak detector <br />psi <br />❑ mechanical Model: <br />minutes <br />❑ electronic Serial #: <br />Secondary piping testing at: <br />❑ line test programmed <br />psi <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Secondary containment repairs for: <br />❑ fail safe Serial #: <br />UDC(s) Piping <br />❑ NA <br />Sump(s) UST(s) <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Corrosion protection <br />❑ fail safe Serial #: <br />Other: see below <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />.❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket Kminimum 5 gallon <br />1 hour hydrostatic ❑ Incon TS -STS <br />Caldwell System ❑ Other <br />• . I r <br />L <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />• . I r <br />L <br />EHD 23-04 <br />Rev 06/22/07 <br />