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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.org <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 1180 S HVV y ` hoof-7 -A G Izv8 <br /> Facility Address: Service Request#: <br /> VAA-moo S* (Y 0 s3 5 S� <br /> Onsite Service Technician's Name: ICC Service Techniciantinstaller Certification#: Manufacturer Training: <br /> (Alvl-u— J s Z S -,2>Do o -7 6-- L4T dR—g3cl 6S6 j <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ 11 mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ElCaldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test programmed ElCaldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El ❑ mechanical Model: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: <br /> El ❑ fail safe Serial #: El Primary <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> p <br /> El positive shutdown Model:El fail safe Serial #: El Secondary <br /> ❑ NA minutes <br /> sensor <br /> El shutdown Model: Secondary containment repairs for: <br /> ❑ ❑ <br /> ❑ fail safe Serial #: UDC(s) 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 /> 7 A 4, <br /> 11, <br /> S Piro <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: .,j R e' By: Title _ <br /> M Y <br /> EHD 23-04 ci <br /> Rev 06/22/07 <br />