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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT - <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Dat <br /> U S A ,� l i n�2► 3(0,l(0 3 7 7o--7 <br /> Facility Address: Service'Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Manufacturer Training: <br /> ViAUIM UVZ1 (t4-M ( 4,AYIA— -771ro 4& V <br /> SERVICE SERVICE <br /> Leak detector �� µ Spill bucket El minimum 5 gallon <br /> mechanical Model: e. —ZDV ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> r` ❑ electronic Serial #: 12 13 ❑ 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 /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 <br /> El electronic Serial #: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fall safe Serial #: <br /> ❑ NA minutes <br /> sensor <br /> El El positive shutdown Model: ElSecond psi piping testing at: <br /> El fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor <br /> ❑ ID positive shutdown Model: El Secondary containment repairs for: Piping <br /> El fail safe Serial #: ( ) p g <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 /> W Ct,,Ail &,,, L A SA-7)'j, <br /> (� A' C/- <br /> o i n� C* w <br /> ��1 s �►� F� � r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: ,/ Recei By: Title: <br /> fZ <br /> A1" <br /> EHD 23-04 <br /> 1/3/07 <br />