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9 SAN JOAQUIN COUNTY 10 <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 JUST J PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Insp1ctiojl)ate: 0 <br />Facility Addrei& S j e Request #: <br />,3fX jjj�j A IVA god k -Ir <br />ol <br />Onsite Service Technician's Name: ICC Ser­vicel(ichnleian/ taller Certification #: Manufacturer Training - <br />3 r% <br />W kA Cl) k4 3101 V19- le4d f /d I <br />I <br />KM�MMII W, =IVA I <br />Ij,3=BM=C-,T ANY -TIME AT EHD'S CURRENT HOURLY RATE. <br />ff V. 1162? NIFIXAMM-1-71l Z M <br />EH® 23-04 <br />Rev 06/22/07 <br />Leak detecto■ r <br />❑ <br />El mechanical Model: <br />El electronic Serial <br />0 line test programmed <br />❑ <br />Leak de■ tector <br />0 mechanical Model: <br />0 electronic Serial <br />0 <br />11 line test programmed <br />Leak detecto■ r <br />0 mechanical Model: <br />❑ <br />0 electronic Serial #: <br />0 line test programmed <br />sensor <br />0 <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />El NA <br />❑ <br />sensor <br />• positive shutdown Model: <br />• fail safe Serial #: <br />�LCold <br />o <br />DNA <br />0 <br />sensor <br />El positive shutdown Model: <br />F1 fail safe Serial #: <br />El NA <br />Drop tube with mechanical overfill at 95% <br />II <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />I <br />KM�MMII W, =IVA I <br />Ij,3=BM=C-,T ANY -TIME AT EHD'S CURRENT HOURLY RATE. <br />ff V. 1162? NIFIXAMM-1-71l Z M <br />EH® 23-04 <br />Rev 06/22/07 <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 11 Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />0 <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />start of monitoring panel <br />�LCold <br />o <br />Corrosion protection <br />0 <br />Other: see below <br />I <br />KM�MMII W, =IVA I <br />Ij,3=BM=C-,T ANY -TIME AT EHD'S CURRENT HOURLY RATE. <br />ff V. 1162? NIFIXAMM-1-71l Z M <br />EH® 23-04 <br />Rev 06/22/07 <br />