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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 9520 -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 <br />ooe____�N <br />MA& qA <br />Date: <br />I � ' 0--7 <br />Facility Address: <br />�� / " <br />Service Request #: <br />SP 00 � Z4 <br />�ti <br />�[/ Lam- - �/ <br />❑ line test programmed <br />Ons' a Service Technician's Name: <br />` <br />Leak detector <br />ICC Service T chnician/Installer Certification #: <br />5 2 s z� it <br />Manufacturer Training: <br />UAx <br />❑ electronic Serial #: <br />-14) -7 I o <br />60e -Ds- 1"/ILO( Ev- CD <br />SERVICE <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 />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />�1 4,Ar•��sensor V&64 <br />❑ <br />❑ positive shutdown Model: 0 _/Vj� <br />ail safe Serial #: <br />'❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />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 />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 />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIM WS CURRENT HOURLY RATE. <br />EHD Insector: Received By:z Title: <br />EHD 23-04 <br />1/3/07 <br />