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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sjgoy.org ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectionate: <br /> 10 23 C6-7 <br /> Facility Address: Service Re uest#: <br /> 61 3 I 4Cr4 UQ- . c , C'v!� Shoo !�- 227�'/ <br /> Onsite Service Technician's Name: ICC Se�;ce Cecn�ian/Inalle �r ific Manufacturer Training: L <br /> qr�} (�I'll� rn` ��/see yy�e11 l V ee� r� M Qin <br /> SERVICE SERVICE <br /> Die5c-4.Leak detector ` v ��, N%�-Spill bucket El minimum 5 gallon <br /> El mechanical mechanical Model: f L !J <br /> I� —1hour hydrostatic ❑ Incon TS-STS <br /> �C electronic Serial #: N o S 2GG 6 <br /> .'.line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector 1Up <br /> Spill bucket El minimum 5 gallon <br /> ElElmechanical Model: n I A,14 A El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> Leak detector ql 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 /> Pri iping testing at: <br /> El Elpositive shutdown Model: � psi <br /> ❑ fail safe Serial #: <br /> b() minutes <br /> El NA <br /> sensor <br /> ❑ positive shutdown Model: S Se ondary piping testing at: <br /> El <br /> El safe Serial #: � � �(psI <br /> JpQ_minutes <br /> El NA <br /> sensor Secondary containment repairs for: o�&,4L <br /> ❑ <br /> El positive shutdown Model: UDC(s) �ti QST Piping <br /> El fail safe Serial #: <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 /> nSi w 4 1e5f V ex/V L i"� 442�k-3 #4 Srs, (d Y°Aj <br /> �� 6� r U/� t/' i P/1 Q2, a S te—. °i est ,//t �Wlc� <br /> 4r l� 3 r P k v 6vt.,, c u3 0 d r,4 &oti, A„ . 2< S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH Spector: Recei B Title: <br /> Ue�J S't r y� v� <br /> I( ¢tel A I� nae t1)� re , <br /> EHD 23-04 <br /> Rev 06/22/07 �C1 <br />