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F <br />SAN JOAQUIN COUNTY <br />*ENVIRONMENTAL HEALTH DEPARTMENO <br />304 East Weber Avenue, Yd 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: Inspection Date: <br />Ytuw- (Tu _76 10/ 1 � 16 -7 <br />Facility Address: Service Request #: <br />6V -YjO C --w I fF At/& 4L&TK(A 7 <br />ICCSeSerfvice Technician/Installer Certification #: Manufacturer Training - <br />Onsite Service Technician's Name: <br />C <br />qj:;�40C7 P <br />J�Z '1 /4 1 , VIC <br />6010 Fvlv juw [(> ( <br />SERVICE <br />Leak detector <br />❑ 0 mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />0 Caldwell System El Other <br />Leak detector <br />❑ <br />0 mechanical Model: <br />[11 hour hydrostatic 0 Incon TS -STS <br />El electronic Serial <br />El Caldwell System El Other <br />El line test programmed <br />— Spill bucket 0 minimum 5 gallon <br />Leak detector <br />0 1 hour hydrostatic El Incon TS -STS <br />M mechanical Model: <br />0 Caldwell System 0 Other <br />0 electronic Serial #: <br />Primary piping testing at: <br />0 line test programme,—' <br />_ psi <br />ensor <br />minutes <br />V0 ositive Shutdown Model: 71 <br />Secondary piping testing at: <br />fail safe Serial #: ZVZO� <br />psi <br />DNA <br />minutes <br />sensor <br />❑ <br />0 positive shutdown Model: <br />UDC(s) Piping <br />0 fail safe Serial #: <br />Sump(s) UST(s) <br />0 NA <br />Cold start of monitoring panel <br />sensor <br />Corrosion protection <br />El positive shutdown Model: <br />❑ <br />[D fail safe Serial <br />EINA <br />El <br />Drop tube with mechanical overfill at 95% <br />D <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 />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System El Other <br />EHD Inspector: <br />__ Spill bucket 0 minimum 5 gallon <br />0 <br />[11 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System El Other <br />— Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />0 <br />_ psi <br />minutes <br />Secondary piping testing at: <br />El <br />psi <br />minutes <br />Secondary containment repairs for: <br />0 <br />UDC(s) Piping <br />Sump(s) UST(s) <br />0 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />0 <br />Other: see below <br />EHD 23-04 <br />1/3/07 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY��D'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />EHD 23-04 <br />1/3/07 <br />