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•SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: %tl -50At3utfl (-L)VwTq Inspection Date: Facility Address: -7000 IJ, kIC H t� CprNl-1 S gl.vO, Service Request #: 5jZ()04CI-7 t 0 Onsite Service Technician's Name: ICC Service Technician/Installer Certifica ' n #: Manufacturer TJraining:O ❑ line test programmed ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: Received BV\Ay: ❑ electronic Serial #: Title: ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ 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 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 TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Received BV\Ay: DMS-- Spill bucket ❑ minimum 5 gallon Title: 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 1/3/07 THIS FACILITY IS SUBJECT TO REINSPECTION AT_ANY TIME AT EHD'S CURRENT HOURLY RATE. EHp Inst ecC&I tor- N)� Received BV\Ay: Title: EHD 23-04 1/3/07