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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN I' 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www_sjgov_orWehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT FacilitNamee: /J en SY U I G�-�J Inspection Date. 9� ❑ ❑ mechanical Model: 64 Facility Address: Service Request #: Onsite Service Technician's Na a ICC Service Technician/Installer Certification #: Manufacturer Training: SERVICE SY U I G�-�J _ Leak detector ❑ ❑ mechanical Model: 64 ❑ electronic Serial #: (I,u 6y 44 L--' ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed 12LJ Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA )1 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) SERVICE SY U I G�-�J Spill bucket ❑ minimum 5 gallon ❑ ❑ I hour hydrostatic ❑ Incon TS -STS 64 ❑ Caldwell System ❑ Other (I,u 6y 44 L--' Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS 12LJ ❑ Caldwell System ❑ Other Recjeiv� ¢y;�'� ,�� Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) ❑ Cold start of monitoring panel ❑ Corrosion protection )1 Other: see below EHD 23-04 Rev 06/22/07 SY U I G�-�J C "I - � S --, I 1 Z S s 11 64 (I,u 6y 44 L--' TH15 FA ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. 12LJ Recjeiv� ¢y;�'� ,�� Title: C EHD 23-04 Rev 06/22/07