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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENO <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 /> 1(Ak O ply- 4-25-off <br /> Facility Address: Service Request#: <br /> U2 W. OArne%(--� (-N . SRo�S�ozS <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training• <br /> 1j 25°1 �k1 � .�'L�1 (0Vj <br /> SERVICE SERVICE <br /> Leak detector , <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> ❑ El El hour hydrostatic ❑ Incon TS-STS <br /> El Serial : <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F-1 <br /> El electronic Serial#: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> 1:1 Caldwell System ❑ Other <br /> sensor <br /> Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> El ❑ fail safe Serial#: ❑ psi <br /> minutes <br /> El NA <br /> sensor <br /> F-1 El shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC s Pi <br /> El fail safe Serial#: ( ) Piping <br /> Sump(s) UST(s) <br /> El 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 /> lmebeu <br /> —wu.� � <br /> a vp(e� — JC-0-(F+e9 C.01�'5LOrJ P� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received B Title: <br /> EHD 23-04 <br /> 1/3/07 <br />