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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENO <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />CAL.. Fa2N�A 5 -roto <br />3 -27-s7 <br />Facility Address: <br />j,S,1j f%A- <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC Service Tech nician/L"UglorCertification #: <br />Manufacturer Training: <br />`LO 15T0"4j.3 <br />wr- F0 01 a -&'b <br />VM1 <br />SERVICE <br />-r— t 4 n kuN <br />Leak detector <br />❑ <br />mechanical Model: V Nt L L.D 2-"v <br />1 LD <br />❑ electronic Serial #: D(otlt 22Z <br />Q I A'l.-'�)o <br />❑ line test programmed <br />❑ <br />'7� Leak detector <br />EHD Inspector: <br />146 mechanical Model: uM1 <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />-r— t 4 n kuN <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />1 LD <br />❑ Caldwell System ❑ Other <br />Q I A'l.-'�)o <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />EHD Inspector: <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ 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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />I -r -c44 ri � u A t % t T vvA,5 TwE (-'ZC— PCS �.jq TWA <br />-r— t 4 n kuN <br />P(tLE v w+cel 15 1-1* qt U), P-C--TLAr1C-jD TtK- <br />rLcrW a- TC" Trc9 IPA 4>5E -D, 2C -T s�j -T-,+C <br />1 LD <br />DIST To C LkA-C— -WC- C dl$�'r L-0 tll �S Ctf LA -c. --D <br />Q I A'l.-'�)o <br />Q,4sS Win, <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY I E T EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Received By: Title: <br />,W-A� <br />EHD 23-04 <br />1/3/07 <br />