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SAN JOAQUIN COUNTY <br /> OVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Far:(209)468-3433 Web: www.sieov.orP/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> A ISS VA PV <br /> Facility Address: Service Request 4: <br /> 14111ab o0-!SL1 -7 <br /> Onsite Service Technician's Name: ICC Service Technuian/Installer Certification#: Manufacturer Training: <br /> g 5313 82 9 U i Zl-2010 6�s-)23 W710 rl <br /> SERVICE SERI <br /> Leak detector Spill bucket <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic <br /> ❑ electronic Serial #: ❑ Caldwell System ---- <br /> ❑ line test programmed L <br /> Leak detector FUELLHF Pt t- <br /> Spill bucket FUEL- HL"Pi'i <br /> ❑ mechanical Model: I ir.51 HM <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic <br /> ❑ line test programmed ❑ Caldwell System I <br /> Leak detector Spill bucket l <br /> ❑ <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic 1111 <br /> ❑ electronic Serial #: El Caldwell System <br /> ❑ line test programmed <br /> sensor F,:6 Htdrun ;,r <br /> ❑ positive shutdown Model: Primary piping testin, H1jW� LHF. }- F <br /> E] ❑ psi FUEL_ Hi.HRH <br /> ❑ fail safe Serial #: DEC 'sii. 200_: <br /> El NA <br /> minutes <br /> sensor Secondary1 in testi <br /> E] 11 positive shutdown Model: ❑ p p g <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> Secondary containmeln Lrts;R a,1.01-Jr'i -- <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) „i;iu'n',;F:+NMJL�R <br /> ❑ fail safe Serial #: <br /> Sump(s, I it.L H1,R11 <br /> ❑ NA LL, iij. 21ou6 11-1:51 HPI <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection L ti:8s t,NNi u.HR <br /> HNNULrik HFH'IE <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below FUEL. "LHRH <br /> DEQ.' lilt. IUtl 111:54 Fif1 <br /> 1 q <br /> µv1 L4 <br /> THIS FACIL TY IS SUBJECT TO REINSPECT/ N AT ANYTIME AT EHD'S CURRENT HOURLY ATE. <br /> EHD Inspector: ^� Receiv d y: Title: <br /> 1 y <br /> EHD 23-04 <br /> Rev 06/22/07 <br />