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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME* <br /> 304 East Weber Avenue,3d Floor, Stockton,CA 95202-2708 <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: Inspection Date: <br /> �00 " 1 1112 11!s-jo—7 <br /> Facility Address: Ser ice 114quest#: <br /> it I <br /> V1 911� f <br /> Onsite Service Tectmicl, n's Name: ICC Service Technician/Installer Certification Manufactu rer TraiAini: <br /> 10-7 V('4tV (p"1 is 107 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket D minimum 5 gallon <br /> F Model: <br /> • -1mechanical <br /> El electronic Serial El 0 1 hour hydrostatic El Incon TS-STS <br /> pgrammed 0 Caldwell System El Other <br /> El line test ro <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> • El mechanical Model: El 0 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial 0 Caldwell System 0 Other <br /> El line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> F1 0 mechanical Model: 0 ® 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial 0 Caldwell System 0 Other <br /> 0 line test proEammed <br /> sensor Primary piping testing at: <br /> 0 D positive shutdown Model: 0 psi <br /> F� fail safe Serial minutes <br /> DNA <br /> sensor Secondary piping testing at: <br /> 0 0 positive shutdown Model: 0 psi <br /> ❑ fail safe Serial#: minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> El El positive shutdown Model: El LTDC(s) Piping <br /> 0 fail safe Serial <br /> EINA Sump(s) UST(s) <br /> 01 Drop tube with mechanical overfill at 95% 4 Cold start of monitoring panel <br /> r-1 Drop tube with mechanical overfill at 95% 11 Corrosion protection <br /> 0 Overfill prevention(see LG letter 150-1) 0 Other: see below <br /> vy'91,Ivf Vf d[A(.( VxAt fIALA m 9121 P-7 <br /> , , litAtAl. at �IALA vu., <br /> tS <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> EH Inspector: Received B Title: <br /> ia <br /> % It <br /> EHD 23-04 <br /> 1/3/07 <br />