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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME* <br />304 East Weber Avenue, 3 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: <br />Inspection Date: <br />0k4 - <br />CE—CI&`) <br />5(l to <br />Facility Address: <br />Received.. �� <br />M ! r�,�/ )� <br />Service Request #: <br />441-� Y <br />/�-lv c <br />flf-stSa6 4i <br />Onsite Service Technician's Name: <br />ICC Service Tec hnician/Installer Certification #: <br />Manufacturer Training: <br />fent <br />❑ line test programmed <br />Leak detector <br />SERVICE <br />Leak detector <br />❑ <br />hd'mechanical Model: �q(p '2tVp <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial <br />Received.. �� <br />M ! r�,�/ )� <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <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 />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill 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 />Received.. �� <br />M ! r�,�/ )� <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 />T' <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector• <br />Y <br />Received.. �� <br />M ! r�,�/ )� <br />Title: <br />EHD 23-04 <br />1/3/07 <br />