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SAN JOAQUIN COUNTY <br /> rENVIRONMENTAL HEALTH DEPARTMEN <br /> b 0 rte. "I h e,34 Floor 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: Inspectio Date <br /> C 4N(Z:o00 L wA� GN�v Qor� '15� j 1 167 <br /> I�<acility(�Address. Service Request� ��s . � <br /> J" V ,V\J 6��4e r S <br /> W-n <br /> Onsite Service Technici 's Name: IC Service Technician/ nstaller Certification#; Manuracturer Training: <br /> 6LN 1 �. Pi ll V f' 1)C r-- tZV6 <br /> SERVICE SERVICE <br /> 1 Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: P L L O — ❑ ❑ 1 hour hydrostatic ❑ lncon TS-STS <br /> t'electronic Serial##: ? 3L4gL ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bu <br /> El ❑ mechanical Model: ❑ ❑ 1 hour hydr <br /> ❑ electronic Serial #: ❑ Caldwell S, <br /> ❑ line test programmed <br /> Leak detector Spill bI I IC LE°aI; <br /> ❑ mechanical Model: 0 <br /> El Ll ❑ 1 hour hydr {_,>wv ; L I IIE >`A I L <br /> 1:1 electronic Serial #: El Caldwell S ruts;"? 1 . 200? 9:L,7 Hrl <br /> ❑ line test programmed <br /> sensor Primary pipin <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutc <br /> ❑ NA <br /> sensor <br /> Secondary p1'I'I'i ;'11k1: 1..f PJI' I_k.ri►: rL;�RPI <br /> i: <br /> ❑ ❑ positive shutdown Model: _ ® psi t L[.,r.� 1�u'rr_;i��Idt.ryl{rt <br /> ❑ fail safe Serial #: rtf�= i '21107 9:57 <br /> art <br /> 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% ❑ 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 /> IJP Y I'1� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME Q'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: , Tidu: <br /> v0-F-j <br /> EHD 23-04 <br /> 1/3/07 <br />