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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.sivov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facilllt Name: <br />.W + A,. W <br />Leak detector <br />Inspection Date: <br />❑ mechanical Model: <br />electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECT"! <br />�rr� til rjr,� <br />Fact tt Address: <br />I gS Ir, <br />earl <br />Service Request #: <br />%f'obsq?,ar- <br />❑ mechanical Model: <br />R2 electronic Serial #: <br />❑ <br />Onsite Service Technician's Na e: <br />C Service Technic' n/Installer Certification #: <br />Manufacturer Training: PIP V� 9 _2-1I <br />�aNc,� c�� <br />�k� <br />S S-110 - x l <br />'�IP� 14'%1 RF vl <br />%I <br />SERVICE <br />.W + A,. W <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECT"! <br />�rr� til rjr,� <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ mechanical Model: <br />R2 electronic Serial #: <br />❑ <br />❑ line test rogrammed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />�} electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />.W + A,. W <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECT"! <br />�rr� til rjr,� <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 />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EVA, ,- O .. UMOU'r , '1 ZTMIK MILIJ <br />.W + A,. W <br />THIS FACILITY IS SUBJECT TO REINSPECT"! <br />�rr� til rjr,� <br />EHD Inspector: <br />` L <br />�A <br />EHD 23-04 ✓ V t <br />Rev 06/22/07 <br />