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SAN JOAQUIN COUNTY <br /> 88 �` k� S>�' AOENVIRONMENTAL HEALTH DEPARTMEN <br /> 6 enue, O' <br /> oo , ockton,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: Inspection Dte: <br /> A . �e,l Gln e- 6I\j 5 723 6-1 <br /> Facility Address: Service Request#: <br /> nsitev Ft44W, wej Cxr , S2 ot) S 031 <br /> Service Technician's Name: ICC Servi a Tech niciananstaller Certification#: Manufacturer Training: <br /> a� m PI' 0 Z <br /> OA CIV A C�• .�,� i <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F1 <br /> El electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed El Caldwell System El Other <br /> sensor Primary piping testing at: V� <br /> ❑ ❑ positive shutdown Model: psi <br /> ❑ fail safe Serial #: too <br /> ❑ NA minutes pv� <br /> sensor <br /> ❑ <br /> El shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> ❑ Secondary containment in repairs for: <br /> El ❑ positive shutdown Model: Pi <br /> El fail safe Serial#: (sPiping <br /> Sumps) UST(s) <br /> El NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> E <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> Overfill prevention (see LG letter 150-1) Other: see below <br /> n S��. n S �� r•� �i�� So'd ��' P� f tAA 14e-(d <br /> W\Ae , Ne k l D AA I kL,, CA C f rPrl`r. fig 146 ra"lam, r-t✓t � <br /> hdte-, /4a—o P vP4,"� Co �i <br /> y�W w 1K� <br /> THIS FACILITY IS SUBJECT fO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E Inspector: Received By: Title: <br /> EHD 23-04 <br /> 1/3/07 <br />