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SAN JOAQUIN COUNTY - <br /> ENVIRONMENTAL HEALTH DEPARTMEN'1'40 <br /> 304 East Weber Avenue,3d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> rt'aA01 QCTfLo k,4 <br /> Facility Address: Service Request#: <br /> 3goo N, M��A a � R� SR 0041155-0 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: 1.A,5,0-1 <br /> 6108 1 ftC-LTz �77-S0 C;4-1 _U T t0-'L-0r7 V N1l L JTF 1410 <br /> SERVICE SERVICE <br /> 1 Leak detector VMk Spill bucket ❑ minimum 5 gallon <br /> 0 mechanical Model: W ^,W E <br /> ,RT ❑ El1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> I Leak detector TIMI Spill bucket ❑ minimum 5 gallon <br /> IS mechanical Model: U7 2W L ❑ ❑ 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: - El _ si <br /> El fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ El positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: <br /> El NA Sump(s) UST(s) <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 ATAY4TaAT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: A ` Receive y: Title: <br /> t /v <br /> EHD 23-04 <br /> 1/3/07 <br />