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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME0 <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax.- (209) 468-3433 Web: www.sjgoy.org�ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fa fity Name: Inspection Date: <br />�Aq 51 N - * 111,01 <br />Facility Addreks: Servic6 Request #: <br />- IM10 0 V1441 " 4-0 <br />Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: nufaurer TrI irp to <br />ice V�- <br />SERVICE <br />Leak detector <br />El 0 1 hour hydrostatic 0 Incon TS -STS <br />El mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDS CURRENT HOURLY RATE. <br />0 electronic Serial <br />El <br />0 line test programmed <br />Leak detector <br />❑ <br />F1 mechanical Model: <br />El <br />0 electronic Serial <br />El line test programmed <br />Leak detector <br />El <br />El mechanical Model: <br />El electronic Serial <br />El line test programmed <br />❑ <br />sensor <br />0 positive shutdown Model: <br />El fail safe Serial <br />El <br />El NA <br />sensor <br />n <br />0 positive shutdown Model: <br />El <br />F-1 fail safe Serial <br />El NA <br />sensor <br />El positive shutdown Model: <br />❑ <br />0 fail safe Serial <br />El NA <br />El <br />Drop tube with mechanical overfill at 95% <br />n <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />El 0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System El Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDS CURRENT HOURLY RATE. <br />Spill bucket El minimum 5 gallon <br />El <br />El I hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />El I hour hydrostatic ❑ Incon TS -STS <br />El Caldwell System 0 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 />El <br />UDC(s) Piping <br />Sump(s) UST(s) <br />n <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />Other: see below <br />I M (PAN <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDS CURRENT HOURLY RATE. <br />'14, W-1,1A11ll Imm" 4 OM2 fl <br />PM- MM81 <br />% I Lloor.'/ 61 <br />EHD 23-04 <br />Rev 06/22/07 <br />