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40 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENt <br />600 East Main Street, Stockton, CA 95202-3029 <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 />(� (.o � 2-Zo SctY <br />Inspection �;e� <br />(/O II <br />Facility A dress:I/ <br />W%I �, 04 MM CA, LJJ VU6g% <br />Service quest #: <br />S�� 6�)T 112749 <br />Service Technician's Name: <br />zk-1 <br />Service Technician/Installer Certification #: <br />lk- <br />T -V'" <br />M1111bt, <br />Manufacturer Training: <br />WNZIC�4011 <br />❑ line test programmed <br />AAA <br />v + <br />SERVICE <br />U Qr1 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />rb <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />ME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />U Qr1 <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 />-AWe 4 <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />rb <br />❑ Caldwell System ❑ Other <br />a N <br />Primary piping testing at: <br />❑ <br />psi <br />ME AT EHD'S CURRENT HOURLY RATE. <br />minutes <br />Sec n2 ary piping testing at: <br />j <br />W <br />Si <br />1� S 8? S- ", `l' � <br />minutes 6() , M AV, <br />S condary containment repairs for: <br />2 UDC(s) Piping <br />Sump(s) UST(s) " <br />❑ <br />Cold start of monitoring panel <br />Corrosion protection , ee-,( YL -11 <br />❑ <br />Other: see below W 0-i , Fi <br />' <br />U Qr1 <br />+� bqf 5 <br />% �e Il' . <br />e�6VL <br />C(-RtU <br />-AWe 4 <br />rb <br />L` I <br />a N <br />ce't Cry V%-ry t , <br />THIS FACILITY IS SUBJECT TO REI NSPEC ON AT ANY <br />ME AT EHD'S CURRENT HOURLY RATE. <br />�EH Inspector: <br />A Vo-, <br />Rece' By: <br />T'tle: <br />f 4#1 e ^n <br />EHD 23-04 <br />Rev 06/22/07 <br />