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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEO <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.orehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE R QUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />k PJ F-nb 31 / a Ira r - <br />Facility Address: Service Request #: <br />34Z5 N S &a a 9 3/ <br />ef- <br />Onsite Service Technician's Name: ICC Service Technician/Install e0ificL <br />n.#:(4 Manufacturer Training: <br />- T <br />en pila �;;q 4!� AZIZ6 <br />SERVICE <br />Leak detector <br />El mechanical Model: <br />F-1 electronic Serial <br />0 line test proEammed <br />Spill bucket El minimum 5 gallon <br />Leak detector <br />0 1 hour hydrostatic El Incon TS -STS <br />13 mechanical Model: <br />El Caldwell System 0 Other <br />11 electronic Serial <br />Spill bucket 0 minimum 5 gallon <br />0 line test programmed <br />El I hour hydrostatic 0 Incon TS -STS <br />. Leak detector <br />❑ <br />El mechanical Model: <br />Primary piping testing at: <br />F-1 electronic Serial <br />psi <br />El line test programmed <br />minutes <br />r('7 STP sensor <br />2e <br />94positive shutdown Model: <br />psi <br />EXail safe Serial #: !kCf, <br />minutes <br />13 NA <br />Secondary containment repairs for: <br />sensor <br />El <br />El positive shutdown Model: <br />Sump(s) UST(s) <br />El fail safe Serial <br />Cold start of monitoring panel <br />DNA <br />Corrosion protection <br />sensor <br />F1 <br />El positive shutdown Model: <br />0 fail safe Serial #: <br />DNA <br />F-1 <br />_ Drop tube with mechanical overfill at 95% <br />F-1 <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) -j <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />0 0 1 hour hydrostatic 0 Incon TS -STS <br />D Caldwell System El Other <br />Spill bucket El minimum 5 gallon <br />1:1 <br />0 1 hour hydrostatic El Incon TS -STS <br />P"'M <br />El Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />El I hour hydrostatic 0 Incon TS -STS <br />El Caldwell System El Other <br />Primary piping testing at: <br />0 <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />El <br />UDC(s) Piping <br />Sump(s) UST(s) <br />0 <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />El <br />Other: see below <br />r MUMA11=10641 <br />THIS- FACILITY IS. -SUBJECT TO REINSPEC ION AN 'S CURRENT HOURLY RATE. <br />1 EHD Inspector: <br />M <br />P"'M <br />EHD 23-04 <br />Rev 06/22/07 <br />