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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />IR <br />304 East Weber Avenue, 3`d 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 REOUEST INSPECTION REPORT <br />Facility Name:`� <br />eAJ � t � f,� �t1 �F�s 5 c.-� Q—. ��` <br />Inspection Date: <br />4 � 30-01 <br />Facility Address: <br />-7MO W. (WUAr— , C�N�� �3�-�/� <br />Service Request #: <br />C)9 wiri1( o <br />Onsite Service Technician's Name: <br />JS1-r?i`1� <br />ICC Service Technician/Installer Certification #: <br />(—�1� 4f`P <br />Manufacturer Training: <br />Received y: <br />g <br />❑ <br />SERVICE <br />S uw-C� <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Received y: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />P}NMk-A(Lsensor <br />❑ <br />❑ positive shutdown Model: L -ALS t <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />Ems+•) 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 />S uw-C� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Received y: <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <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 />UDC(s) Piping <br />Cs� E Sump(s) UST(s) <br />tt <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />�- P�4sS�ro •^e <br />S uw-C� <br />-"l t.,f£ PU-t I_T -CCO <br />( Niel A C)jJ <br />THIS FACILITY IS SUBJECT TO REINSPECTION T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: N <br />�L !ya <br />Received y: <br />Titl <br />v iv <br />EHD 23-04 <br />1/3/07 <br />