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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEqN <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgoy.or ehd <br />UNDERGROUND STORAGE TANUST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />u v eIIA01 <br />Facili& Aildress: SerVceklwest #: <br />/' n /V �/- %4104 r/4 <br />Onsite Service Technicidn's Name: ICC Service Technician/Installer Certification #: <br />SERVICE <br />MA <br />13 <br />EHD 23-04 <br />Rev 06/22/07 <br />SERVICE <br />Leak detector <br />Spill bucket 0 minimum 5 gallon <br />1:1 mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />F-1 electronic Serial <br />0 Caldwell System 0 Other <br />0 line test programmed <br />Spill bucket 0 minimum 5 gallon <br />Leak dete■ ctor <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 mechanical Model: <br />El Caldwell System F-1 Other <br />F■ -1 electronic Serial <br />Spill bucket El minimum 5 gallon <br />0- line test programmed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />I Leak detecto■ r <br />El Caldwell System El Other <br />■ mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial <br />psi <br />El line test programmed <br />minutes <br />senso■ r <br />Secondary piping testing at: <br />0 positive shutdown Model: <br />Psi, <br />0 fail safe Serial #: <br />minutes <br />El NA <br />Secondary containment repairs for: <br />senso■ r <br />UDC(s) Piping <br />El positive shutdown Model: <br />Sump(s) UST(s) <br />r-1 fail safe Serial <br />Cold start of monitoring panel <br />0 NA <br />Corrosion protection <br />senso■ r <br />Other: see below <br />El positive shutdown Model: <br />F-1 fail safe Serial <br />0 NA <br />Drop tube with mechanical overfill at 95% <br />Mi <br />Drop tube with mechanical overfill at 95% <br />M967 <br />= -"I WKID <br />MA <br />13 <br />EHD 23-04 <br />Rev 06/22/07 <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />1:1 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System F-1 Other <br />Spill bucket El minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System El Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />0 <br />Psi, <br />minutes <br />Secondary containment repairs for: <br />0 <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />0 <br />Other: see below <br />M <br />Vi W/4MMM I& MFJFW�15M" <br />eceived By <br />A� <br />■ <br />I M F-2 Fm W -A <br />