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O;A V 1 ry SAN JOAQUIN COUNTY -+ _NVIRONMENTAL HEALTH DEPARTMENT N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.segov.org/ehd cA��koR�'�P UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Leak detector ❑ Facility Address: Service Request #: ❑ electronic Serial #: THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. Onsite Service Technician's N me: I= Service T nicianllnstaller Exp. Date: Training: ❑ ❑ mechanical Model: \M/anufacturer 1--�.._ / v i V 11 I SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ line test programmed ❑ 1 hour h: Leak detector ❑ ❑ mechanical Model: Primary pip ❑ electronic Serial #.- :❑ ❑ 0line test programmed S3 sensor ❑ positive shutdown Model: V' (Z- OrNC-LAA>� — Testing for t by: ❑ fail safe Serial #: on A Note: Please be aw L! '_' - I •� 1 i ' t ` j upon 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) M/ This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hvdroct�:-+ire r-, I--_ ❑ Caldwell Spill THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ ❑ 1 hour h: Te ❑ Caldwell Primary pip ❑ psi minu Secondary 1 ❑ Testing for t by: Note: Please be aw L! '_' - I •� 1 i ' t ` j upon installation, 6 month start of I I'=:r E = t H " •' Corrosion pr Other: see b—,, ElCold ❑ ❑ ❑ This UST facility is NOT APPROVED to operate v, EHD THIS CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. E H D Iec Received By - Te 04 Rev 4 UST SERVICE REQUEST INSPECTION REPORT