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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DELTA <br />304 East Weber Avenue, P 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: I Inspection Date: <br />12 aL -7 1(o 10-7 <br />Facility Address: Service Request #: <br />c) -7 <br />Onsite service Technician's Name: ICC Service Technician/Gs&ller Certification Manufacturer Training: <br />D'0 5 -z,+ -?-- � t I - LA r <br />EHD 23-04 <br />1/3/07 <br />Leak detector <br />D <br />El mechanical Model: <br />0 electronic Serial #: <br />El line test programmed <br />0 <br />Leak detector <br />El <br />El mechanical Model: <br />El electronic Serial #: <br />n <br />El line test programmed <br />Leak detector <br />0 <br />0 mechanical Model: <br />0 <br />El electronic Serial #: <br />0 line test programmed <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 NA <br />❑ <br />sensor <br />0 positive shutdown Model: <br />El <br />0 fail safe Serial <br />El <br />0 NA <br />❑ <br />sensor <br />El <br />El positive shutdown Model: <br />F1 fail safe Serial #: <br />DNA <br />F-1 <br />Drop tube with mechanical overfill at 95% <br />0 <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />EHD 23-04 <br />1/3/07 <br />OPP Spill bucket NKminimum 5 gallon <br />R� <br />El I hour hydrostatic El Incon TS -STS <br />9"Caldwell System El Other <br />Spill bucket El minimum 5 gallon <br />0 <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket El minimum 5 gallon <br />n <br />0 1 hour hydrostatic 0 Incon. TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />0 <br />psi <br />minutes <br />Second*- piping testing at: <br />F-1 <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 />El <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />1/3/07 <br />