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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:wwW.sjgoy.orgLehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Dat <br /> A <br /> "W LAVII IQ 41K 10-1 <br /> Facility Address: Servite Request#: <br /> n A <br /> VIAW(r) (AV11 %luglt-1/ <br /> Onsite Skrviie Technician's Name: ICC Se an/Installer Certification#: a ufagutrer Tr!*!!, <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El El mechanical Model: 0 0 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> 0 line test programmed <br /> Leak detector Spill bucket F-1 minimum 5 gallon <br /> 0 0 mechanical Model: 0 El I hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial #: 0 Caldwell System El Other <br /> El line test programmed <br /> Leak detector -Spill bucket El minimum 5 gallon <br /> 0 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> n electronic Serial #: 11 Caldwell System 0 Other <br /> El line test programmed <br /> sensor <br /> tutdown Model: Primary piping testing at: <br /> positive r El psi <br /> EA fail safe Serial #: aq:ia <br /> minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> ❑ 0 positive shutdown Model: El psi <br /> 0 fail safe Serial 9: minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> 0 positive shutdown Model: ❑ UDC(s) Piping <br /> El fail safe Serial Sump(s) UST(s) <br /> El NA <br /> 0 Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> J0 Drop tube with mechanical overfill at 95% El Corrosion protection <br /> E] Ove Ill prevention(see LG letter 150-1) 0 Other: see below <br /> $I 4-o <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIAT EH 'S CURRENT HOURLY RATE. <br /> EHDInspector: Receiv <br /> fm qUIA4 <br /> EHD 23-04 L <br /> Rev 06/22/07 <br />