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SAN JOAQUIN COUNTY a <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/eh <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />au(4 SSP <br />Inspection Date: <br />1z/11107 <br />Facility Address: <br />N 44NIV -,Wfe�;F, O/W <br />Service Request #: <br />S2ad 52,' � <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />'fit <br />4- — 0, <br />! AJC 3 <br />SERVICE <br />51ps.r C-.-,— <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Rece' By: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />EDDrop <br />tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />51ps.r C-.-,— <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Rece' By: <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: 8'1, Cl <br />if <br />c psi <br />minutes <br />Secondary containment repairs for: <br />-Z - UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below pV f- (& p U <br />Ad !s� <br />51ps.r C-.-,— <br />) A WDA <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />NIC <br />Rece' By: <br />Title: <br />EHD 23-04 <br />Rev 06/22/1 <br />