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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br /> Telephone: (209)468-3420 Paz:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> If klil'f0 -7• 12- <br /> Facility Address: Service Request#: <br /> 23?-1;-N . V D ITL S,"40*-0 05 ) 14'-�-,> <br /> Onsite Service Technician's ame: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> cj� &W � J X10-7 I�t� fir& µ0A / <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket E3 minimum 5 gallon <br /> ❑ F-1 electronic Serial ❑ El hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed El Caldwell System El Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programme,—' <br /> sensor <br /> ❑ El positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> El El positive shutdown Model: ❑ Secondary piping testing at: <br /> 1:1 fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: ( ) p g <br /> ❑ NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below <br /> �k&A <br /> I'h ss6reA to aq <br /> ge— <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> In IPCIbr: Received By: e: <br /> OVA <br /> EHD 23-04 I� <br /> 1/3/07 <br />