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SAN JOAQUIN COUNTY <br /> V <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/chd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> RwoND AN i ufU A^ a 21-1,11116-7 <br /> Facility Address: Service Request#: <br /> vS, CG, erbeexl Levi S20v Ll 101� 6 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> i1Gf Np 1)uMlde/' Upl r!� tGC�b�i <br /> 9 6 1 r <br /> SERVICE SERVICE <br /> Leak detector 1-e Pe,+-0 <br /> Xmechanical Model: $TG -Ai16d -F Spill bucket El minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 1% 160 gQ-] ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ElElmechanical Model: El El <br /> 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: El Caldwell System ElOther <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El — si <br /> El fail safe Serial#: p <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Pi <br /> ❑ fail safe Serial #: ( ) Piping <br /> El NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> W el � ^ <br /> e s /leve MetiA4/ iL� WIC eC/�V v- \TA Ci 77- <br /> A J I Q <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHDI ctor: Received Title: <br /> U/-� /� <br /> EHD 23-04 <br /> 1/3/07 <br />