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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEV <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sil;oy.or ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Q IGS 7 w 17� 7 1c)-7 <br /> Facility Address: Service Request#: <br /> l.un 1arkLAYAVV R ��oo s-z32�1 <br /> Lervice Technician's Name: ICC Service Technician/In taller Certification#: Manufacturer Training: <br /> �� 975-77-01 ( —GAT VMI iZ31 i Z3Z- <br /> SERVICE SERVICE <br /> Q mecLeak detector <br /> hanical Model: M ua I CrD O91 Spill bucket Eminimum 5 gallon <br /> Elelectronic Serial#: D20 61gc 10 Rl hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> 011 Leak detector Spill bucket ❑ minimum 5 gallon <br /> Q. mechanical Model: qla 241T7J ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 1020 0/3 06 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ Elpositive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Secondary piping testing at: <br /> si <br /> El fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% [E] <br /> Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% Corrosion protection <br /> ElOverfill prevention(see LG letter 150-1) Other: see below <br /> 4tj� <br /> !� Gam►. ,�cd� to sZ C7 1- 2( Lid <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector- /�n - Received Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />