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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENO <br />304 East Weber Avenue, P 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 />� . Te td/.) -4- <br />Inspection Date: <br />Lt/,z 0 / 07 <br />Facility Address: <br />Service Ikequest #: <br />Onsite/Service Technician'sName: <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />"i I , l C <br />O 9 <br />V sL.4_a— A?'e v�_ <br />SERVICE <br />b 4 i ;tAj <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />+-P <br />❑ electronic Serial #: <br />-MS <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />ANY TIME AT EHD'S CURRENT HOURLY RATE S <br />❑ mechanical Model: <br />❑ <br />�] electronic Serial #: <br />k ❑ 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 />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 />b 4 i ;tAj <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon. TS -STS <br />+-P <br />❑ Caldwell System ❑ Other <br />-MS <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 />ANY TIME AT EHD'S CURRENT HOURLY RATE S <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 />Other: see below <br />�qf-7L. u r%, = a L.rvn H N. -w.: S I.v%A0 f I I. T h 173 <br />o n 5 5 e- r <br />b 4 i ;tAj <br />v �' 6 -► p �1 % <br />5 -1( 10 <br />A re, N1 Q P i <br />+-P <br />1 C.� f_v r _qr1\ <br />-MS <br />- 3 S_p So � > <br />1 o 4t -i 4 f <br />w <br />Sin Loj 1 <br />THIS FACILITY IS SUBJEfCT TO REINSPECTION At <br />ANY TIME AT EHD'S CURRENT HOURLY RATE S <br />EHD ector: <br />14x__1 Vt-\ 9VI—) <br />R ived By: <br />Title: <br />I 4-zo -o <br />EHD 23-04 <br />1/3/07 <br />