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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: p P I PQ�� Inspection te: P (e:? /I / ve Leak detector ❑ Facility dress: C) w C Service R quest #4. 13K 06 �q �8o site Service Technician's Name: pro� ICC Service Technician/Installer Certification #: Manufacturer Training: SERVICE V� r rb 1 07 " L Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Title: 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 prevention (see LG letter 150-1) SERVICE V� r rb 1 07 " L �n v 1 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 Title: ❑ 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 ❑ Other: see below n 1 V� r rb 1 07 " L V12 M 1-1, �- %��- 4 THIS FACILITY IS SUBJECT TO REINSPECTIO T ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Ins tor: -� u", YL-- eceiv 4-�z Title: 1•aQ EHD 23-04 Rev 06/22/07