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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sj og v.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: (� <br />b,' IN (,,- 0 b <br />Inspection Date.. <br />5, � ° 01 <br />Facility � � <br />Service Request #: <br />512. o ;3 / <br />On • e Service Technician's Name:ICC <br />Service Technician/Installer Certification #: <br />Manufacturer Trainin : <br />Glt s (w <br />❑ line test programmed <br />✓v � r I <br />SERVICE <br />C411 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Vk <br />❑ electronic Serial #: <br />Glt s (w <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />C411 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Vk <br />❑ Caldwell System ❑ Other <br />Glt s (w <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />GlA9Jb C�/►'LI�Gt�Snv� Lt <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />�f 6k,011� "Mz L <br />C411 <br />#M q <br />j4w— 4 Lvt± 14 <br />Vk <br />Glt s (w <br />oL . <br />41�W AAS <br />GlA9Jb C�/►'LI�Gt�Snv� Lt <br />oc)vkosw <br />THIS FACILITY IS SUBJEJCT <br />TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />E D Insp tor: <br />—PM#47<- <br />Rece <br />I iv By: <br />Tide: k <br />tj0b Y� <br />k -a Al <br />EHD 23-04 <br />Rev 06/22/07 <br />