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9 SAN JOAQUIN COUNTY It ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.or /g ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: ✓–�� f vUV �` � IMJf Insp ion te: r��'O� Facility Address:Service CCfo Request #: Onsite Service Technician's Name: ICC Service Technicia �VV• }}��I``n/Istaller Certification #: (Manufacturer Training: `' A ❑ line test programmed ❑ Leak detector -, SERVICE � � � •�i�i �1..•y Leak detector ❑ ❑ mechanical Model: 13 a TOT MA, ❑ electronic Serial #: A T.��uSll, l ....i1. s Y , �,. ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE � � � •�i�i �1..•y p 4l Spill bucket minimum 5 gallon nco TS -STS KI—hour hydrostatic ❑ Inco,)" ❑ Caldwell System Others 'r„ :'k� 13 a TOT MA, � A T.��uSll, l ....i1. s Y , �,. Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) ❑ Cold start of monitoring panel ❑ Corrosion protection -� ❑ Other: see below � ♦� �� l �� V nomas � ley � �� L�..I�1J� � � � � •�i�i �1..•y 1 KNE' 13 a TOT MA, A T.��uSll, l ....i1. s Y , �,. .,• �: • • . • �.� EHD 23-04