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SAN JOAQUIN COUNTY <br />loENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: v.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fadlity Name: I Inspection Date: <br />( I I A <br />ANJJV6V� /jA <br />FaciiiiyXddress: VService Request #: <br />12, t 1 k), C-01DOS 1� <br />. nsitp Service Tec linician 9 s Nam JICC Service Tee ni ian/installer Certification #: Manufacturer Tr fining: <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />Leak detector <br />El <br />0 mechanical Model: <br />Spill bucket 0 minimum 5 gallon <br />F-1 electronic Serial #: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 jine test projEammed <br />R Caldwell System El Other <br />" Leak detector <br />Spill bucket 0 minimum 5 gallon <br />0 mechanical Model: <br />R I hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial #: <br />El Caldwell System 0 Other <br />0 line test 2rolEammed <br />Primary piping testing at: <br />. Leak detector <br />❑ <br />0 mechanical Model: <br />minutes <br />0 electronic Serial #: <br />Secondary piping testing at: <br />0 line test proffammed. <br />psi <br />93 R ensor <br />V <br />minutes <br />0 positive shutdown Model: <br />Secondary containment repairs for: <br />'1714 fail safe Serial #--tj� <br />UDC(s) Piping <br />[*:Ol NA <br />Sump(s) UST(s) <br />0 h-11 sensor <br />Cold start of monitoring panel <br />0 positive shutdown Model: <br />Corrosion protection <br />)0 fail safe Serial #: <br />Other: see below <br />0 NA <br />4—tMf 9�ensor <br />Cl positive sbutdown. Model: <br />fail safe Serial #: k OA rd <br />ONA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />ro <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />❑ R I hour hydrostatic 0 Incon. TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />R Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />R I 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 />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />0 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />0 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />lots <br />I ffil <br />EHD 23-04 <br />Rev 06/22/07 <br />