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e <br /> 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 Date: <br /> USA Gfto I f-Al— 361 4-161 31116-7 <br /> Facility Address: Service Request#: <br /> ZC4Cy? w. I ��lev�PK j GN: Lobi s11*2 009 7 7 `j <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> CSI' y oo w t l I i 4-r*-) U Nl z <br /> SERVICE SERVICE <br /> Leak detector \f <br /> Spill bucket El minimum 5 gallon <br /> mechanical Model: C.D-2,0b D ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: &17./7-1 L ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El electronic Serial F-1El1 hour hydrostatic El Incon TS-STS <br /> 1:1 line test programmed El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> ❑ <br /> El positive shutdown Model: ❑ Secondary piping testing at: <br /> El fall safe Serial #: p <br /> ❑ NA minutes <br /> sensor <br /> Secondary containment repairs for: <br /> El El positive shutdown Model: ElPi in <br /> El fail safe Serial #: ( ) Piping <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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD pector: iJ` Receive y: Title: <br /> EHD 23-04 <br /> 1/3/07 <br />