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SAN JOAQUIN COUNTY <br />VIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-008 <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: r� <br />Inspection Date: <br />Facility Address: U <br />qk� <br />vd N1Qnn C -,A" <br />Service Request #: <br />I <br />❑ electronic Serial #: 0607 of, Ti <br />, <br />❑ line test programmed <br />Onsite Service Technician's Name: <br />Leak detector <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />6.,,Nv6E Juf1RC-z <br />❑ electronic Serial #: <br />vuK ► 0 066 <br />4Z 3S 3-76o F -C moo. <br />SERVICE <br />Jg(1,eak detector <br />❑ <br />R'mechanical Model: Ft- 0942O W fir; <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: 0607 of, Ti <br />Title: _ <br />11'rJ CQ E <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 />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />F <br />ll prevention (see LG letter 150-1) <br />SERVICE <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 EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Title: _ <br />11'rJ CQ E <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: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />1/3/07 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: Rec ed By: <br />` %V A44< -JZ 6GGt,tk <br />Title: _ <br />11'rJ CQ E <br />EHD 23-04 <br />1/3/07 <br />