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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, P Floor, Stockton, CA 95202-2708 <br /> Telephone: (209)468-3420 lax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> W M„�l M�--r 3-o b-0-7 <br /> Facility Address: Service Request#: <br /> 25��S s , Par 5� QasS S V-0 046101105 <br /> Onsite Service Technician's Name: ICC Service Technician/Ii1SLaNer Certification#: Manufacturer Training: <br /> 1, K, gANCMU, -0-1 tic I R" J A"t— <br /> SERVICE SERVICE <br /> �Z Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: y� ❑ ❑ 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 <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial : ElEl1 hour hydrostatic 1:1Incon TS-STS <br /> El line test programmed <br /> 1:1 Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: El psi piping testing at: <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor <br /> El El positive shutdown Model: El Secondary containment repairs for: Piping <br /> El fail safe Serial #: O p <br /> El NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> IV <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receiv y: Title: / <br /> EHD 23-04 <br /> 1/3/07 <br />