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0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENO <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 />Inspectio Date: <br />Facility Address: <br />F r A N !C lnle� <br />C Y 2 f 0� �Ol�i <br />Service Request #: <br />S < (DOE pow <br />Onsite Service Technician's Name: <br />01 �' - <br />ICC Service TFician/I staller Certification #: <br />.3 <br />Manufacturer Training: <br />T <br />V <br />-IC <br />lV <br />SERVICE <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 By: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />❑ <br />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 />00S�`L Spill bucket )?minimum 5 gallon <br />er f bf'),�/ <br />] it 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 K Other (t4SN V41,, <br />Received By: <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />111 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 />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />A(r1A A� 1t00Pr-,, pwPl WAS oui-, 21., WWA- azc <br />►�' Lar b 0 M V,\ <br />er f bf'),�/ <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe K�;� <br />Received By: <br />Title: <br />EHD 23-04 <br />1/3/07 <br />