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SAN JOAQUIN COUNTY 1p <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/�ehd <br />UNDERGROUND STORAGE TANK UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />le- a,.4,v C>I' I * 2.72 O5 L1j+ <9 � -31 zdc) <br />Facility Address: • <br />-2- <br />-z- He% L -,M --A--% 4 N 3,.-- 4 14 <br />Onsite Service Technician's Name: ICC Sirvice Technician/Install <br />&— A <br />Lbe-4 � <br />SERVICE <br />'SP- 005 3 57 3 3 <br />Certification #: Manufacturer Training: =T'<mj <br />02921 <br />0 <br />SERVICE <br />Leak detector <br />El <br />0 mechanical Model: <br />F-1 I hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System 0 Other <br />El line test progammed <br />- Spill bucket 0 minimum 5 gallon <br />Leak detector <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El mechanical Model: <br />0 Caldwell System 0 Other <br />0 electronic Serial #: <br />- Spill bucket 0 minimum 5 gallon <br />0 line test programmed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />I Leak detector <br />0 <br />El mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial #: <br />psi <br />El line test programmed <br />minutes <br />sensor <br />El <br />0 positive shutdown Model: <br />psi <br />0 fail safe Serial #: <br />minutes <br />0 NA <br />Secondary containment repairs for: <br />sensor <br />UDC(s) Piping <br />0 positive shutdown Model: <br />Sump(s) UST(s) <br />F-1 fail safe Serial <br />Cold start of monitoring panel <br />DNA <br />Corrosion protection <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 NA <br />El <br />- Drop tube with mechanical overfill at 95% <br />FE -11 <br />Drop tube with mechanical overfill at 95% <br />ED] <br />Overfill prevention (see LG letter 150-1) <br />'SP- 005 3 57 3 3 <br />Certification #: Manufacturer Training: =T'<mj <br />02921 <br />0 <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />0 <br />F-1 I hour hydrostatic 0 Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPE A INF'rIRAC ArC----- <br />0 Caldwell System 0 Other <br />- Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />- Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 11 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />El <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />0 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />Other: see below <br />END 23-04 <br />Rev 06/22/07 <br />THIS FACILITY IS SUBJECT TO REINSPE A INF'rIRAC ArC----- <br />EHD Inspector: P- <br />END 23-04 <br />Rev 06/22/07 <br />