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rSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: wwwsigov.org/eh UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: —' ✓.t�P v� vim`- Inspection Date: Ot"t M pt PrN ct- C hr) B P 1►J L 3 26 I o 'rj Facility Address: Received j R-4��y 1 Service Request #: q93 M o ,*,f Rvl v -d t M aiv e-gc,, 5 O o57o5r6 Onsite ice Technician's ame: _ 2u c.z;g� -''°n2 ICC Service Technician/installer Certification #: Manufacturer Training: ❑ electronic Serial #: ,�Z C - �c $ `1 Z — u T 61 A 3113,1 2141 SERVICE —' ✓.t�P v� vim`- Leak detector ❑ ❑ mechanical Model: THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ electronic Serial #: Received j R-4��y 1 ❑ 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: [A ❑ 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 — —' ✓.t�P v� vim`- Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Received j R-4��y 1 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) [A Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below g6vA 4v Eve-, U aL. —' ✓.t�P v� vim`- L THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector:_ ` r ^ w _ I Received j R-4��y 1 Title: ' A EHD 23-04 RPS n6/22W