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SAN JOAQUIN COUNTY <br /> �� A xn ENVIRONMENTAL HEALTH DEPARTMEN <br /> t"lJ+ -40d ue, , Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectionte: <br /> Ckgr }e-1x- W4 Chevy,./ �. T lL-/`b-7 <br /> Facility Address: VVA`") t G C� L/ Service <br /> Request# 0616 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Cerlifi-atioa#: Manufacturer Training: <br /> i� rib V ee q<r <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hor.ir hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 0 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> 01 sensor S-rp Sup''' P Primary piping testing at: <br /> 14 positive shutdown Model: 7- 69 <br /> El psi <br /> gI fail safe Serial#: minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% FED <br /> Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) Other: see below <br /> Lit-I �2 � SD/ Uf�.�G�-��� ►4' � �' �i � � � <br /> L- n- lti IZr r tom. h.ifs4 <br /> S <br /> `C C4t* tr <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ector: Re a y: title: <br /> EHD 23-04 <br /> 1/3/07 <br />