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SAN JOAQUIN COUNTY <br />0 ENVIRONMENTAL HEALTH DEPARTMENIO <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 lax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />�tjuI oil G P,0 -V -j J& #/- qfej 411C 101 <br />Facility Address: . I I ServIce RquAit #: <br />Onsite Service T <br />ICC Service <br />0 <br />SERVICE <br />Leak detector <br />El 0 mechanical Model: <br />0 electronic Serial <br />El line test programmed <br />0 Caldwell System El Other <br />Leak detector <br />❑ <br />F-1 mechanical Model: <br />El 1 hour hydrostatic El Incon TS -STS <br />El electronic Serial #: <br />El Caldwell System El Other <br />El line test programmed <br />- Spill bucket 0 minimum 5 gallon <br />Leak detector <br />El <br />0 mechanical Model: <br />El Caldwell System 0 Other <br />0 electronic Serial #: <br />Primary piping testing at: <br />0 line test programmed <br />psi <br />sensor <br />0 <br />0 positive shutdown Model: <br />Secondary piping testing at: <br />El fail safe Serial <br />psi <br />El NA <br />minutes <br />sensor <br />0 <br />El positive shutdown Model: <br />UDC(s) Piping <br />El fail safe Serial #: <br />Sump(s) UST(s) <br />EINA <br />Cold start of monitoring panel <br />sensor <br />❑ <br />0 positive shutdown Model: <br />Other: see below <br />El fail safe Serial #: <br />El NA <br />0 <br />_ Drop tube with mechanical overfill at 95% <br />❑F <br />Drop tube with mechanical overfill at 95% <br />❑Overfill <br />prevention (see LG letter 150-1) <br />M, <br />M! <br />V 1;0 (,e -731 <br />Installer Certification #:facturer Training: qv em - <br />F_ SERVICE <br />LN'TeM "MR AM MP MW P11M It' Will (TAIM �= M4, Tl�o, � FREF FAR= <br />wiffmmWAIRMIM1 W f A MEAST"t 4,01M jnllftllc�� <br />"'--THIS KACILITY IS SUBJECT TO REIIMSPWT• M �i III Z. <br />Inspector.- <br />izr*ir <br />EHD 23-04 <br />1/3/07 <br />Spill bucket El minimum 5 gallon <br />El <br />El 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />El 1 hour hydrostatic El Incon TS -STS <br />El Caldwell System El Other <br />- Spill bucket 0 minimum 5 gallon <br />0 <br />[11 hour hydrostatic 0 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 />F1 <br />UDC(s) Piping <br />A <br />Sump(s) UST(s) <br />9 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />0 <br />Other: see below <br />LN'TeM "MR AM MP MW P11M It' Will (TAIM �= M4, Tl�o, � FREF FAR= <br />wiffmmWAIRMIM1 W f A MEAST"t 4,01M jnllftllc�� <br />"'--THIS KACILITY IS SUBJECT TO REIIMSPWT• M �i III Z. <br />Inspector.- <br />izr*ir <br />EHD 23-04 <br />1/3/07 <br />