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C SAN JOAQUIN COUNTY %.w ENVIRONMENTAL HEALTH DEPARTME"177W 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sit:ov,ore/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: rw -(0 1 , �A ��,.r Inspection Date: ' ZD Facility Addre : ❑ mechanical Model: Servic equest #: Oo 5q3ea Onsi a Service Technician's Name: ❑ line test proEammed ICC Service IMiciantinstallerrtification #: Manufacturer Training: ❑ mechanical Model: ❑ ❑ e!sectronic Serial #: ❑ SERVICE , �A ��,.r Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test proEammed ❑ Leak detector ❑ mechanical Model: ❑ ❑ e!sectronic Serial #: ❑ ❑ line test programmed Leak detector ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE , �A ��,.r Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hourhydrostatic ❑ Incon TS -STS 'MEW. ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ I hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below t , �A ��,.r e� .,L. t _,, 'MEW. THIS FACILITY IS SUBJECT TO REINSPECTIONHOURLY EHD 23-04 Rev 06/22/07