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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <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 />dv% 49 f S6D A211VTDu% <br />Inspection Date. <br />❑ <br />❑ mechanical Model: <br />UN 9- ucXVID <br />Facility Address: <br />N QMT RX l C.4F-- ,Fefy <br />Service Request #: <br />158D <br />Rolu <br />5125 Z--? <br />Onsite Service Technician's Name:I <br />Received By: <br />C Service Technician/Installer Certification #: <br />Manufacturer Training: <br />5� �i <br />�1�2 <br />5242+91 - C471- - <br />T <br />SERVICE <br />dv% 49 f S6D A211VTDu% <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />UN 9- ucXVID <br />❑ electronic Serial #: <br />N QMT RX l C.4F-- ,Fefy <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Received By: <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 />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />E ' <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 />dv% 49 f S6D A211VTDu% <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />UN 9- ucXVID <br />❑ Caldwell System ❑ Other <br />N QMT RX l C.4F-- ,Fefy <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />EHD Inspector: W1 • rq (A� <br />❑ Caldwell System ❑ Other <br />Received By: <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 />4 �} UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />E ' <br />Other: see below -aV iQ) l SD <br />I W&M 15- <br />dv% 49 f S6D A211VTDu% <br />3 4 F1 #At 26k, &P <br />UN 9- ucXVID <br />S <br />N QMT RX l C.4F-- ,Fefy <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: W1 • rq (A� <br />Received By: <br />Title: <br />EHD 23-04 <br />1/3/07 <br />