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0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/eh <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />E{0060--J 6 w� <br />v 1& 1 �^ <br />Inspecti Dat <br />27 O v <br />Facility Address: <br />322 E, CA <br />L <br />Sj�rb[Z/'h#1J C <br />Servicif Request #: <br />S0) �;- �j Z07 <br />Onsite Service Technician's Name: <br />ICC Service Technician/installer Certification #: <br />Manufacturer Training: <br />rf1rA1/q0:z6/0//0 <br />-ra=61616 <br />V M7�- <br />SERVICE <br />of cp� ,i; �Ari <br />ifL Leak detector <br />❑ <br />A mechanical Model. L Q �i Ur3 U <br />L4 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: 0-1 2 1 <br />Receiv By: 01 <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />of cp� ,i; �Ari <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Receiv By: 01 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <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 />❑ <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 <br />RPv ns/99W <br />of cp� ,i; �Ari <br />L l C Gd. <br />11,061) <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHA Inspector: G <br />Vim/ <br />Receiv By: 01 <br />Title: <br />EHD 23-04 <br />RPv ns/99W <br />