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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sieov.ore/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />-< <br />Facility Address: I <br />Service Request #: rj 0'0 SS 4 'f <br />/,/� / <br />ReceiveV: <br />OnsitService Technician's Name: <br />ICC Service Technician/installer Certification #: <br />Manufacturer Training: /O <br />YY W `I <br />os..ai 'LG1� <br />t�S' unt <br />SERVICE <br />'Gal �, A Ole-. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />ReceiveV: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />9-po24 sensor <br />S--- Model: <br />Nd fail safe Seria b <br />❑ <br />❑ NA <br />❑ <br />Ve,+(w7c., sensor <br />21�positive shutdown Model: ZOg <br />.R fail safe Serial #: 7/7-o3o <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />4❑ <br />❑ <br />Overfill prevention (see LO letter 150-1) <br />SERVICE <br />'Gal �, A Ole-. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ hicon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />ReceiveV: <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />1 i.A s AT -&-s4 Ll. oz/fS1.� Ski.- Qgrs. <br />'Gal �, A Ole-. <br />++�%s <br />oto+jam �,., t.✓or-(ee.� <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />ReceiveV: <br />Title: <br />v/ <br />EHD 23-04 <br />Rev 06/22/07 <br />►J <br />