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SAN JOAQUIN COUNTY VIRONMENTAL 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: -1 - Z/o7 Facility Address: Service Request #: 3 cl N A1N M r sw#ooggz60 Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: ,31M NuTOWS S-z.Wia4--" r P 30G- - SERVICE Leak detector ❑ ❑ mechanical Model: THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ electronic Serial #: Rece d $ y: VM ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line testprogramineAd 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 °I Spill bucket ❑ minimum 5 gallon GYl hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Rece d $ y: VM 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 minutes 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 pcaid THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: to V Rece d $ y: VM Title: e j U EHD 23-04 1/3/07