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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd 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: Inspection Date: <br /> fMT LAWC- C&JM t VkA4,A1 V-23--o'1 <br /> Facility Address: Service Request#: <br /> wo E. 0- V9 11P SRao�bl5y <br /> Onsite Service Technician's Name: ICC Service Technician/Inerelier Certification#: Manufacturer Training: <br /> MATT Esq"- 4E-r 6-10-0Z Vc <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ElElModel: ❑ El1 hour hydrostatic ElIncon TS-STS <br /> El electronic Serial #: <br /> [I line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ hicon 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 ❑ hicon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> PibS(l.. NsensorA."wKt-r Primary piping testing at: <br /> ❑ positive shutdown Model: SJR 'W5 <br /> ❑ fail safe Serial #: El psi <br /> ❑ NA minutes <br /> 19-7 sensor OLmi tke <br /> El positive shutdown Model: �fR 31)3 Secondary piping testing at: <br /> ❑ psi <br /> El fail safe Serial#: mi <br /> El NA <br /> minutes <br /> q( tF DS V sensor ank.lar Secondary containment repairs for: <br /> ❑ positive shutdown Model: \)R- 303 ❑ 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) ❑ I Other: see below <br /> V&-(Fro L0�hJ U(Qk L 0 tr W&H U Qu LP Ak AW <br /> THIS FACILITY IS SUBJECT TO REINSPECTI T Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received Title <br /> LLLt � <br /> EHD 23-04 <br /> 1/3/07 <br />