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SAN JOAQUIN COUNTY WVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sis;ov.org/ehd 1TNnRRGR01TND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: u I a & ir P 6rllep Facility Address: Service Request #: 1590 w InIWA( si /RIPON 5(-v 053'717 - Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: WCC JtA A RE Z S3,o tj o '16 LAT -7f-10 SERVICE Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: Rec ed By: .4 ❑ line test programmed ❑ Leak detector ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA Q4 sensor ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Rec ed By: .4 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) " ❑ Cold start of monitoring panel ❑ Corrosion protection Q4 Other: see below o ftktr AT W4WJ" z i6 P161 c.) -- nf+SW THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: l Rec ed By: .4 Title: 1I v. EHD 23-04 ` J Rev 06/22/07