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•SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEP <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sii!ov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />PPS, - 0^44er WA 1a& <br />Ins pe ion ate: <br />'P16*169 <br />Facility Address: <br />(/j, ctl*r}' V L <br />Service kequest : <br />S /zoU -� <br />Onsite Service Technician's Name: <br />A -f <br />I C SerAce Technician/Installer Certification #: <br />�5-&M <br />Manufacturer raining: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />ai A�� <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />'V 0 F7 5S�. <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT A Y I <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />Title: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ f: '" fe 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 />1 Spill bucket Wminimum 5 gallon <br />-S:a <br />❑ 1 hour hydrostatic con TS -STS <br />❑ Caldwell System XOther <br />ai A�� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />CC j2 1 Atr4l ma <br />❑ Caldwell System ❑ Other <br />'V 0 F7 5S�. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT A Y I <br />❑ Caldwell System ❑ Other <br />E Spector: K117eived <br />U - \, <br />Primary piping testing at: <br />❑ <br />psi <br />Title: <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 />EHD 23-04 U <br />Rev 06/22/07 <br />I <br />-S:a <br />ai A�� <br />c W 4S <br />CC j2 1 Atr4l ma <br />'V 0 F7 5S�. <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT A Y I <br />E AT EHD'S CURRENT HOURLY RATE. <br />E Spector: K117eived <br />U - \, <br />By: <br />Title: <br />EHD 23-04 U <br />Rev 06/22/07 <br />