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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEXO� <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> Inspection Date. <br /> 11/11 <br /> Y) d <br /> Facility Address: Servieb Re est k: <br /> Onsite Service Techniciahl Name: ICC Service Technician/Installer Certification#: 1V>jaangfact e T�raiini <br /> Ag <br /> M <br /> ' <br /> .1�;qmo A &WAt Al S kv. 013joi <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> 0 mechanical Model: El 0 1 hour hydrostatic El Incon TS-STS <br /> F-1 electronic Serial #: 0 Caldwell System El Other <br /> 0 line test proEammed — I <br /> Leak detector —Spill bucket F-1 minimum 5 gallon <br /> ❑ 0 mechanical Model: 0 0 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System El Other <br /> El line test programmed <br /> I Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial #: El Caldwell System 0 Other <br /> 0 line test programmed <br /> I !Mfo '1sensor CqAw <br /> ositive shutdown Mo el:g #1 Primary piping testing at: <br /> ,p -177 71/ - psi <br /> 9-fail safe Serial 1:1 minutes <br /> 0 NA <br /> S Ansor Secondary piping testing at: <br /> ositive STUIltdown Model: /7"(ff 7VI) <br /> fail safe Serial ❑ <br /> #: 0 —psi <br /> minutes <br /> 0 NA <br /> sensor Secondary containment repairs for: <br /> El El positive shutdown Model: D UDC(s) Piping <br /> F-1 fail safe Serial #: <br /> El NA Sump(s) UST(s) <br /> D Drop tube with mechanical overfill at 95% S6 Cold start of monitoring panel <br /> R Drop tube with mechanical overfill at 95% El Corrosion protection <br /> 0 . Overfill prevention(see LG letter 150-1) 0 Other: see below <br /> vie <br /> M16'6-'\ sls�tm all �nY 6V WA A AAiMqA4/u9 <br /> a,10171 <br /> vou'r. C-420, 'I�qv '�W LK lyid�df '0 (710, ain5ov'-- <br /> tam') WIL u "'AACU'l '9r—V SOW A?,5W oAKS <br /> tHIS FXCII ATY Is _UBJE&Td REI RSPI CT101k 4AAVNYTI'ME AT EH 'S CURRENT IHURL FY RATE. <br /> EHD Inspr tor:or: Title: <br /> WA . RvtL- 41&" <br /> EHD 23-04 <br /> Rev 06/22/07 <br />