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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN', <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 lax:(209)468-3433 Web: www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> CI1,LA y,F- 1. O\ tt-, PA- As(--& 2_g—o-1 <br /> Facility Address: Service Request#: <br /> 1' '$i S. �1A,M LANA S2004-)" I <br /> Onsite Service Technician's Name: ICC Service Ieehwieien/Installer Certification#: Manufacturer Training: <br /> JOAO PJuMAA-A 525214ob —U � �,r1 frG, EN�t� <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial El El hour hydrostatic ElIncon TS-STS <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> El El positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: S psi <br /> Elfail safe Serial #: <br /> (0 0 minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: j UDC(s) Piping <br /> ❑ fail safe Serial #: 'DS- 5-T-P 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 /> �E�5 C,-- ST P S vM P — CAL--v im- A-CCo -rEs-r p+4s5�,D <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rec Title: <br /> UL- <br /> EHD 23-04 <br /> 1/3/07 <br />