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0 SAN 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 sieov.ory,/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> fir W G e 2 13 0f? <br /> Facility Address: IService Request#: <br /> U W- C JaI-u 0-7Z <br /> Onsite Service Technician's Name: ICC Tice Tec niciaN nstall Certification#: Manufacturer Training: <br /> �-cp 2, <br /> /2 <br /> SERVICE SERVICE <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 /> 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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> 11 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 /> El fail safe Serial #: minutes <br /> ❑ NA <br /> sensor <br /> Secondary piping testing at: �-�j <br /> E] ❑ positive shutdown Model: psi C. <br /> El fail safe Serial#: -.tom minutes C <br /> ❑ NA �� I . l!>.'3 <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> F­1 Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> F-1Droptube with mechanical overfill at 95% Corrosion protection V e , I� <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> Si Vere <br /> No ¢v-� Of&kI we1eiRN .( h <br /> b,Q esu, c r,� ( a l� e <br /> Lerma prXi ur A-�- <br /> /v (a A o►J t L Mil /k <br /> THIS FACILITY tqTHOLURLY IS SUBJECT TO REINSPEC ON AT ANY TIME AT EHD' C R ERATE. <br /> EH Spector: Rece d By: T t �� <br /> vUn I <br /> EHD 23-04 <br /> Rev 6/22/07 <br />