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iSAN 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.s' ov.or ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: lnspect" n date: <br /> IU G Lvb r`J AA 1 () C Mr / 01 <br /> Facility Address: Servici Request : <br /> Lf 2 � S. A �r or � Mo SQL S/ o(D S (o(2) l �7 <br /> Onsite Technician's Name: [CC Service Technicia Installer Certification#: Manufacturer Training• <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial #: El 1 hour hydrostatic �. <br /> El line test ro ammed El Caldwell System <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket <br /> El ❑ ❑ 1 hour hydrostatic <br /> El electronic Serial #: ❑ Caldwell System <br /> ❑ line test programmed <br /> Leak detector I I:«.1. ,,i.�r:ri <br /> El mechanical Model: Spill bucket I...1rip 6. nir�r +:I,:, Ill I <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic <br /> ❑ line test programmed ❑ Caldwell System <br /> sensor <br /> po it"ve shutdown Model: 2 Q Primary piping testing <br /> ❑ psi <br /> $Vail safe Serial #: 71(0, 5yy minutes <br /> ❑ NA J, ki :. <br /> „I I I .. ,'t <br /> sensor Secondary P pin i g testi] <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containmen ,� <br /> �,.. . <br /> El positive shutdown Model: ❑ UDC(s <br /> _ _ _1'Er1 ; r��'j a+_, rE�._>zT <br /> ❑ fail safe Serial#: i :Fll HbiPl1 <br /> NA Sump(; <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitorir <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> Pk <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO I E A 'S CURRENT HOURLY RATE. <br /> EHD1 ector: f� Poe <br /> Rceeived By: Title: <br /> EHD 23-04 <br /> Rev 06122107 <br />