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SAN JOAQUIN COUNTY 2NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siQov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT F 'lity Name: Inspection Date: 0 '07 Facility Address: V Ivul Iw- /(0 �1- Inj N+ Service Request #: 34a�9101 Onsite Service Technician's Name: V [CC Service Teechn'cian/Installer Certification #: Manufacturer Training: Received By: All O 1VAi 11 SERVICE Leak detector ❑ ❑ mechanical Model: THIS FACILITY IS SUBJECT TO REINSPECTION A ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ electronic Serial #: Received By: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic 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 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REINSPECTION A ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Received By: Spill bucket ❑ minimum. 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 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 s r0m• �Wmel,�Io THIS FACILITY IS SUBJECT TO REINSPECTION A ANY TIME AT EHD'S CURRENT HOURLY RATE. Lucto . Received By: Title: EHD 23-04 Rev 06/22/07