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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN, <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:m�.sjgoy.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Agc® W Pnl 3l1 lop <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> ro kE �i�4 1U,# S '�7- u i A 21 26�7- <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostati <br /> ❑ electronic Serial #: ❑ Caldwell System <br /> ❑ line test programmed 15' <br /> Leak detector <br /> El mechanical Model: Spill bucket <br /> ❑ <br /> El electronic Serial #: El El 1 hour hydrostati _Er1,_:,_,, Fil-, P1 <br /> El line test programmed <br /> El Caldwell System t_ r,:`; TI ih.1E;I IdE 'SHI IP <br /> ;LJ11P <br /> Leak detector �Eras,_;>? 11WT HLHPt°1 <br /> ❑ mechanical Model: 7q SVt) —373 Spill bucket 11H1 14. 2008 1 u:Cr3 H[1 <br /> ❑ ❑ electronic Serial #: Zp Cr or(, ❑ ❑ 1 hour hydrostati <br /> ❑ line test programmed ❑ Caldwell System <br /> °) S/P sensor <br /> 7failsitive shutdown Model: Primary piping testis <br /> safe Serial #: El psi <br /> minutes <br /> El NA <br /> sensor L <br /> Secondary piping te., E;14 <br /> ❑ positive shutdown Model: F 1JE1 t;Lr F-11 <br /> ❑ ❑ fail safe Serial #: ❑ psi r1r;F; 14, 21008 10:09 i-41 <br /> ❑ NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> El fail safe Serial #: ( ) p g <br /> ❑ 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 /> "I � S- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receive Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />