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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.sjgov.org�efid <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />v 11 K Q,c ftvlo <br />s o l <br />Facility Address: <br />Service Aequest #: <br />WILM vcn G✓u Y� <br />lZo5►S <br />Onsite S &vice Technician's Name: <br />J" <br />ICC Service Technician/Installer Certification #:��a/�p�ufac <br />r Trai ing: <br />"Y,f S� � ���� IL��. <br />❑ <br />Elmechanical Model: <br />EHD Inspector: Rec ived By: <br />SERVICE <br />a W jAv. (j[ n �d A <br />Leak detector <br />ElElmechanical <br />Model: <br />❑ electronic Serial #: <br />i-✓ <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />Elmechanical Model: <br />EHD Inspector: Rec ived By: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />Ei <br />h� sensor <br />CJ/positive shutdown Model: 16L'2�0 j44 <br />❑ <br />Cj fail safe ( 61V Serial <br />❑ NA 6 <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />4fail safe (stm✓�,1Serial #: <br />""'I / <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />E❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />I 'I I <br />SERVICE <br />a W jAv. (j[ n �d A <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />i-✓ <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD Inspector: Rec ived By: <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />a W jAv. (j[ n �d A <br />i-✓ <br />Iry <br />THS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: Rec ived By: <br />Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />