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SAN JOAQUIN COUNTY 0 <br />*ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:s[gpv.orgehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: inspection Date. <br />CaTco 41 2S)og <br />Facility Address: Service Request #: <br />2��,Go �� � I ,M�n s (Z v v ��i o �7 <br />Onsite Service Technician's Name: ICC Service Technicianllnstaller Certification #: Manufacturer Training: <br />L Zl� gt 4l a 52� 555-7 - LA-L,�' ' <br />SERVICE <br />Leak detector <br />❑ ❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ ❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ ❑ mechanical Model: <br />electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ ❑ positive shutdown Model: <br />❑ fall safe Serial #: <br />❑ NA <br />sensor <br />❑ ❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ ❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ Drop tube with mechanical overfill at 95% <br />❑ Drop tube with mechanical overfill at 95% <br />El Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ ancon TS -STS <br />❑ Caldwell System O Other <br />Spill bucket ❑ minimum 5 gallon <br />Ll ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ psi <br />minutes <br />Secondary piping testing at: <br />❑ psi <br />minutes <br />Secondary containment repairs for: <br />❑ UDC(s) Piping <br />Sump(s) 'UST(s) <br />❑ Cold start of monitoring panel <br />❑ Corrosion protection <br />Other: see below <br />C O�u <br />/I.-- Irij n�' -A e te>-d-� Aci <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EIID lnspectar: Received By: Title: <br />A/�l <br />EHD 23-04 <br />Rev 06/22/07 <br />