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0 SAN JOAQUIN COUNTY 44 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s' ov.org/ehd <br />rTNn>E+'.RC:ROITND STORAGE TANK. (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: _ <br />Inspectio Date: <br />) 12, l v `7 <br />Leak detector <br />❑ <br />Facility Address: <br />�b Duck C r v, �01 S�04_ L -r <br />Service Request #: <br />S/Z 00 I 3 <br />Onsite Service Technician's Name: <br />SCI Servi a echnicia Installer Certification #: <br />Manufacturer Training: <br />15 tvNzt� e <br />b <br />SERVICE <br />�fit1111� �` <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ Caldwell System ❑ Other <br />t2 t-) hu '99S <br />❑ electronic Serial #: <br />Ll <br />❑ line test programmed <br />Leak detector <br />ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />f, `Vlzp -1--,-o CIA <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />�fit1111� �` <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />t2 t-) hu '99S <br />Spill bucket ❑ minimum 5 gallon <br />Ll <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ I hour hydrostatic ❑ Incon TS -STS <br />f, `Vlzp -1--,-o CIA <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />psi 5k,p 4t4^S S -i -I1 <br />%Q minutes ��enS �il-h S'wvp tv <br />rs �'� <br />Secondary containment�a for : <br />UDC(s) Piping <br />-rf.prs -In,—Sump(s) UST(s) <br />❑ <br />1 Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />Iie �QL�1V <br />�fit1111� �` <br />�O <br />`I 'lam r U►-� S�t, r ., <br />�tsLe, reel, 2N o <br />v}� - NeN 0IN" I A1 <br />Ga <br />V Or\ 4rA,) i in <br />t2 t-) hu '99S <br />THIS FACILITY IS SUBJECT TO REINSPECTIqaAT <br />ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHp Ins ectx V � V� <br />Rece' <br />fit <br />f, `Vlzp -1--,-o CIA <br />EHD 23-04 <br />Rev 06122/07 <br />4;Ekvl� �- k4r�� _\_ - <br />