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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME9 <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.orz/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />CtevR-v N <br />;lA (o8 <br />Facility Address: <br />Service Request #: <br />X03 s nom, �1 M <br />5roC) 7,z 61 l <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />GGA - 676ffco, <br />S - ckT <br />n Pc,J ey. Sj-z,(-jt0 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />1-zy .� _ Z _ �► <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />R ived B <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 />EYJ <br />gq Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />0 <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />1-zy .� _ Z _ �► <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />OR INSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />R ived B <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 />06 s -- t l 6g?— <br />(A & (A& <br />N4 —x = �i2�- 3N <br />80/ <br />1-zy .� _ Z _ �► <br />7-1 r� <br />RiS e v <br />THIS FACILITY IS S�UIBJECT <br />OR INSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector. Gz�`C/V�► <br />lVv <br />R ived B <br />Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />