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SAN JOAQUIN COUNTY <br />• ENVIRONMENTAL HEALTH DEPARTME <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sieov.ore/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REOUEST INSPECTION REPORT <br />Facility Name: �y� /,per <br />G/G fam. <br />Inspection Date: <br />p� <br />�/Zg/OO <br />Facility Address: <br />33q- M MAJ &T -AC -ii fZU06k <br />Service Request #: <br />NDr yff- Mtenifb <br />, <br />, <br />Onsite Service Technician's Name: <br />ICC Service TechniciaNlnstaller Certification #: <br />Manufacturer Training: <br />/<.ie(s ,Ba?I[ <br />5ZOt7793 <br />83370q <br />SERVICE <br />zl F L1 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJEcIr TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Received By: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />/1Al�lut nsor <br />`f�1 <br />d <br />V positive shutdown Model: 07*390� <br />❑ fail safe Serial #: G47/3 ( <br />❑ NA <br />❑ <br />sensor <br />positive shutdown Model: V l l q 316-/{[Iq <br />❑ <br />❑ fail safe Serial #: (230j40 <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />zl F L1 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJEcIr TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Received By: <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />zl F L1 <br />R 1 - RtZe-1 /i-7 (07 " ahW Ak -iziAnJ <br />rt�d WRA Pi -1,'7 -/ZS"" <br />THIS FACILITY IS SUBJEcIr TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspmtoe <br />Received By: <br />Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />