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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 Far: (209) 468-3433 Web: www.sigov.org/ehd <br />I1NDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />j �e4,�Ze4A ArW 41AJ!d 0 -LCL e�fl <br />Inspection Date: <br />p VIA .,o <br />❑ mechanical Model: <br />Facility Address: <br />/- 3 <br />too ad <br />Service Request #: <br />52 o o S7 5 2 - <br />Onsite Service Technician's Name: <br />Onsite <br />Leak detector <br />ICC Service Technician/Installer Certification #: <br />((W�� <br />b <br />Manufacturer Training: <br />A a" 0 3 <br />ke rw) 0 <br />❑ electronic Serial #: <br />ICGI�Sb��i$1 —u I 0 <br />❑ line test programmed <br />SERVICE <br />j �e4,�Ze4A ArW 41AJ!d 0 -LCL e�fl <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />Recei By: <br />I <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ positive shutdown Model: <br />❑ <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 />j �e4,�Ze4A ArW 41AJ!d 0 -LCL e�fl <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Recei By: <br />I <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 />s "'GI - <br />j �e4,�Ze4A ArW 41AJ!d 0 -LCL e�fl <br />-r" <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Insptor: ^'q� nnV,, A,tA <br />/"'J <br />Recei By: <br />I <br />Titrt. _ <br />EHD 23-04 <br />Rev qi (?V/07 <br />