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1W SAN JOAQUIN COUNTY 19 <br />ENVIRONMENTAL HEALTH DEPARTMENT It <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax.- (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT. <br />Facility Name: ool, Inspection Date: <br />ills _l� a <br />Faci it Adilress:ruce <br />Se * Request #: <br />CA I�Slfo <br />Onsite Service Techniciall'silame: ICC Service Technician/installer Certification #: I 6rp[T'T —c-�W-W fff C-171,;tjot"n <br />0 <br />SERVICE <br />Leak detector <br />Spill bucket 0 minimum 5 gallon <br />11 mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System 0 Other <br />0 line test proffammed <br />Spill bucket El minimum 5 gallon <br />Leak detector <br />❑ <br />0 mechanical Model: <br />0 Caldwell System 0 Other <br />0 electronic Serial <br />- Spill bucket F-1 minimum 5 gallon <br />0 line test 2rogammed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />. Leak detector <br />❑ <br />0 mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial #: <br />psi <br />0 line test proffammed <br />minutes <br />sensor <br />❑ <br />0 positive shutdown Model: <br />SI <br />0 fail safe Serial <br />minutes <br />DNA <br />Secondary containment repairs for: <br />sensor <br />R <br />0 positive shutdown Model: <br />Sump(s) UST(s) <br />El fail safe Serial <br />Cold start of monitoring panel <br />DNA <br />Corrosion protection <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />DNA <br />0 <br />Drop tube with mechanical overfill at 95% <br />n <br />Drop tube with mechanical overfill at 95% <br />0 <br />Overfill prevention (see LG letter 150-1) <br />0 <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket El minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />- Spill bucket F-1 minimum 5 gallon <br />F-1 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 11 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />SI <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />.-W <br />Other: see belowfVM <br />T <br />W SM W" <br />I—, Toi IN 1 40111*10 W—N NO TITIM MT, <br />EHD Insp <br />MAII III A W11:1 <br />■ <br />4M <br />