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0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REOUEST INSPECTION REPORT Facility Name: (� oO Z krdec��ecolcxc3 Inspectionate: r3 �� Facility Addres : o ( w. cr��, Service Request #: 6 s� O/n�siitte Service Technician's Name: A ICC Service Technician/installer Certification #: Manufacturer TTrrainiinng: SERVICE ru �A#ntit Ne,�--1 jjg4169 1a eakdetector vMT {, V mechanical Model: '079 -L � 2�w �d ❑ electronic Serial #: (jtzU 3 « 1 ❑ 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 ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill revention (see LG letter 150-1) L\ I\ IN`s J r" 0, 1 o, a r^ t vwJ L. SERVICE ru �A#ntit Ne,�--1 jjg4169 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 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Title: 4." 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 ❑ Other: see below _I, - On s t1U'r �'% ru �A#ntit Ne,�--1 jjg4169 v -i- Tcs W6 THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. E Inspector: U Received By: Title: 4." EHD 23-04 / Rev 06/22/07