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SAN JOAQUIN COUNTY `ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, 3Td 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: Inspec tonlate: *d1ity ❑ mechanical Model: �61 ddress: Service Request #: AHq A✓# 0i" Onsite ervice Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: ❑ electronic Serial #: ❑ ❑ line test programmed SERVICE V. e✓ l K Ild Leak detector F-1 ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: 56 ❑ 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 V. e✓ l K Ild 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 I ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) ❑ Cold start of monitoring panel 56 Corrosion protection V' ✓ ;es ❑ Other: see below EHD 23-04 (� 1/3/07 V. e✓ l K Ild o J t loVV �IAI11C. V1 i C tV THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. H1 Inspecto A : Rec ived By: � I EHD 23-04 (� 1/3/07