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/*MNL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgoy.orgLehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Avc,c, i / -?,I Facility Address: 2 " Onsite Service Technician's Name: IC Semc ServiceRequest #: Certification #: Manufacturer Traini SERVICE Leak detector ❑ 0 1 hour hydrostatic El Incon TS -STS mechanical Model: \)mr Co Lo 2,000 0 electronic Serial #: jMOLf 1452_ ❑ 0 line test prog2mmed Leak detector ❑ ❑ mechanical Model: El El electronic Serial #: El line test programmed Leak detector ❑ F-1 mechanical Model: 0 electronic Serial #: El line test programmed F-1 sensor F-1 0 positive shutdown Model: 0 fail safe Serial #: El El NA sensor ❑ 0 positive shutdown Model: El 0 fail safe Serial #: 0 El NA sensor El 0 positive shutdown Model: 0 fail safe Serial #: 0 NA El Drop tube with mechanical overfill at 95% F-1 _ Drop tube with mechanical overfill at 95% 0 Overfill prevention (see LG letter 150-1) ServiceRequest #: Certification #: Manufacturer Traini SERVICE Spill bucket El minimum 5 gallon ❑ 0 1 hour hydrostatic El Incon TS -STS 0 Caldwell System 0 Other Spill bucket El minimum 5 gallon ❑ 0 1 hour hydrostatic 0 Incon TS -STS 0 Caldwell System 0 Other - Spill bucket 0 minimum 5 gallon El 0 1 hour hydrostatic 0 Incon TS -STS El Caldwell System 0 Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: F-1 psi minutes Secondary containment repairs for: El UDC(s) Piping Sump(s) UST(s) 0 Cold start of monitoring panel El Corrosion protection 0 Other: see below EHD 23-04 Rev 06/22/07 THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDS CURRENT HOURLY RATE. EHD 23-04 Rev 06/22/07