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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT p� MQ in S -f - , 4etM- d F , Stockton, CA 95202-2708 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: o f &( C S Z- : Inspection D7/6-4/0 6 -7 Facility Address: S. 61,1ero02G �-^�, La i Service Request #: y�'ooS 0-72 Onsite'Service Technician's Name: ICC Service Tech ni ian/Installer Certification #: Manufacturer Training: t r ^ z--, ❑ electronic Serial #:O V,0,0-7 UM SERVICE Leak detector ❑ mechanical Model:, — L bZ Wo ce, 6 e� wire. -?o 1C,i1 ❑ electronic Serial #:O V,0,0-7 ❑ ❑ line test programmed EHD Insp or:�% V M Leak detector UM Model: �� ` �- o goo ceived B x mechanical ❑ ❑ 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 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ce, 6 e� wire. ❑ Caldwell System ❑ Other 1C,i1 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS EHD Insp or:�% V M ❑ Caldwell System ❑ Other ceived B 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 EHD 23-04 1/3/07 (a-46 ce, 6 e� wire. 1C,i1 THIS FACILITY IS SUBJECT TO REI NSPE AT ANYTIME AT EHD'S CURRENT HOURLY RATE. EHD Insp or:�% V M I � ceived B Title: Se'l"u',r- TPL'1-1 EHD 23-04 1/3/07