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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT FacilZ�rm- " zm P Inspection Date: lD - (T '01 Facility Address: dv-a+ �*A-m 64 Service Request #: Onsite Service Technician's Name: ICC Service Technician/Installer Cr UW&� c rtification #: (o-*— Manufacturer Trai ing: v+ - SERVICE WtUlamAz k ) tM t Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: E Insp to A & i; ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model` ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed All sensor positive shutdown Model: ��" � of *0 ❑ fail safe Serial#: NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE WtUlamAz k ) tM t Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -WS ❑ Caldwell System ❑ Other E Insp to A & i; Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) ' ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below EHD 23-04 Rev 06/22/07 WtUlamAz k ) tM t THIS FACILITY IS SUBJECT TO REINSPECTI AT APY TIME AT EHD'S CURRENT HOURLY RATE. E Insp to A & i; X -J -iv By: I "t, Aze-q — Title: I EHD 23-04 Rev 06/22/07