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0 SAN JOAQUIN COUNTY 1-0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK IUST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />MI i cV- S72) 12,117107 <br />Facility Address: Service Request #: <br />Z-7 <br />Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />0 eA -tj,-j,'0tn CA (/I 7�W f <br />SERVICE <br />- Spill bucket 0 minimum 5 gallon <br />Leak detector <br />El' <br />El mechanical Model: <br />El Caldwell System 0 Other <br />F-1 electronic Serial #: <br />Spill bucket 0 minimum 5 gallon <br />0 line test prorammed <br />0 1 hour hydrostatic F-1 Incon TS -STS <br />Leak detector <br />❑ <br />F-1 mechanical Model: <br />Spill bucket El minimum 5 gallon <br />❑ electronic Serial #: <br />0 1 hour hydrostatic El Incon TS -STS <br />0 line test programmed <br />0 Caldwell System 0 Other <br />I Leak detector <br />El <br />El mechanical Model: <br />psi <br />0 electronic Serial #: <br />minutes <br />El line test programmed <br />Secondary piping testing at: <br />sensor <br />F-1 <br />El positive shutdown Model: <br />minutes <br />El fail safe Serial #: <br />Secondary containment repairs for: <br />El NA <br />UDC(s) Piping <br />sensor <br />❑ <br />0 positive shutdown Model: <br />Cold start of monitoring panel <br />0 fail safe Serial #: <br />Corrosion protection <br />DNA <br />Other: see below <br />sensor <br />❑ <br />El positive shutdown Model: <br />0 fail safe Serial #: <br />El NA <br />F-1 <br />Drop tube with mechanical overfill at 95% <br />F-1 <br />Drop tube with mechanical overfill at 95%- <br />0 El <br />Overfill prevention (see LG letter 150-1) <br />A I <br />zpfd S)�A, jy&-j amdu�l Aa� Lz, pl, cli�p <br />- Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic E-1 Incon TS -STS <br />El Caldwell System 0 Other <br />EHD Inspector <br />0 , <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic F-1 Incon TS -STS <br />F-1 Caldwell System F-1 Other <br />Spill bucket El minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />El <br />UDC(s) Piping <br />Sump(s) UST(s) <br />B" <br />Cold start of monitoring panel <br />F-1 <br />Corrosion protection <br />0 <br />Other: see below <br />A I <br />zpfd S)�A, jy&-j amdu�l Aa� Lz, pl, cli�p <br />"Od Afik—' alJ nl) 'v,-( <br />A <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector <br />0 , <br />EHD 23-04 <br />1/3/07 <br />