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SAN JOAQUIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <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 REQUEST INSPECTION REPORT <br />Facility Name: <br />c I - <br />Inspection Date: <br />3 -2,q--(3 ---� <br />i <br />❑ <br />Facility Address:�/� <br />ServiceRequest#- I o <br />1Z.- 'BES <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />SERVICE <br />+-.;- a <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Received B <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 />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 />❑ 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 />Drop tube with mechanical overfill at 95% <br />J=Overfill <br />prevention (see LG letter 150-1) <br />SERVICE <br />+-.;- a <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Received B <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 />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />Corrosion protection <br />❑ <br />Other: see below <br />VAor d Pi-okol'.th-#4tty icat <br />+-.;- a <br />Fvw ZL vs ;vim Li g <br />jt-{ s <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EI pectr: <br />CM oil 4� 7 <br />Received B <br />Title: <br />EHD 23-04 <br />1/3/07 <br />