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SAN JOAQUIN COUNTY <br />*NVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3d 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 />rob P PrIF ('0 q I / 5 ) o g <br />Facility Address: Service Request #: <br />14q -4L PO 06Wt,6 <br />Onsite Service Technician's Name: <br />6(AAb^WPF, rA(NrftZ <br />12o gam, U�n+ieop <br />ICC Service Technician/Installer Certification <br />5 Z 3?) 45V — (4 7- � ate <br />ROM= <br />Manufacturer Training: <br />/1.3®178 61 u -z-;) � <br />Leak detector <br />El <br />F-1 mechanical Model: <br />F-1 electronic Serial #: <br />EHD Inspector: <br />--29 110AM <br />El line test proEammed <br />0 <br />Leak detector <br />❑ <br />El mechanical Model: <br />F-1 electronic Serial #: <br />El <br />El line test programmed <br />. Leak detector <br />F-1 <br />0 mechanical Model: <br />❑ <br />0 electronic Serial #: <br />0 line test prorammed <br />sensor <br />0 <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />EINA <br />F-1 <br />sensor <br />❑ <br />El positive shutdown Model: <br />4'Cold <br />0 fail safe Serial <br />El <br />El NA <br />El <br />sensor <br />❑ <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />DNA <br />El <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />0 <br />Overfill prevention (see LG letter 150-1) —j <br />ROM= <br />Manufacturer Training: <br />/1.3®178 61 u -z-;) � <br />K awrij- �V' <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 />EHD Inspector: <br />--29 110AM <br />Spill bucket 0 minimum 5 gallon <br />0 <br />El I hour hydrostatic D Incon TS -STS <br />El Caldwell System El Other <br />- Spill bucket El minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />D 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 />F-1 <br />UDC(s) Piping <br />Sump(s) UST(s) <br />4'Cold <br />start of monitoring panel <br />El <br />Corrosion protection <br />El <br />I Other: see below <br />K awrij- �V' <br />4T A,7m <br />N ag "I[oil] tj W&ZYA" <br />EHD Inspector: <br />--29 110AM <br />EHD 23-04 <br />1/3/07 <br />