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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: 061 161� r� 11 0 -7 Facility ddress: I I Servi a Re uest #: U(j 01 ,n„ 6W Q 5v—pap Sa I " Onsite Sirvice Technician's Name: N.'(6145 I?j-) ICC Service Technician/Installer Certification #: Manufacturer Training: opw- 3o3'I 21;P • SERVICE o'S�y,� Leak detector ❑ ❑ mechanical Model: 0 ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: I ❑ line test programmed HIS AC LI Y 1§ SUBJECT Tb 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 o'S�y,� Spill bucket minimum 5 gallon t 1 hour hydrostatic Incon TS -STS 0 ❑ Caldwell System Other�,� 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 I minutes HIS AC LI Y 1§ SUBJECT Tb 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 EHD 23-04 1/3/07 'm. h ✓ t B c: 0 W)�( v� I a s a ✓C9►� HIS AC LI Y 1§ SUBJECT Tb REINS ECTION & AWTIML AT EAb,s CU RENT HO RLY RATE. GIns ector. Rece ed By: tic. EHD 23-04 1/3/07 'm.