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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 -- <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 />Ne-� 4 ©CL, 0 9 2-1 <br />Instion Date: <br />S Za�00 <br />Facility Address: <br />3300 W ATS2 LO -0 /lb . <br />Service Request #: <br />S < 00 -�;" Sq E2 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training <br />01t- 6 L06 <br />r1211110 <br />❑ line test programmed <br />❑ <br />SERVICE <br />,n s j - S IL <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPE ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />R ved By: <br />ch� <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 />61 W p r2.sensor <br />❑ <br />)Cpositive shutdown Model: Z03 <br />,fail safe Serial #: 900 <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 />EDrop <br />tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />,n s j - S IL <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPE ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />R ved By: <br />ch� <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 />A r r-' t <br />,n s j - S IL <br />THIS FACILITY IS SUBJECT TO REINSPE ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EH spector•. <br />R ved By: <br />ch� <br />Titl <br />EHD 23-04 <br />