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SAN JOAQUIN COUNTY <br /> t ENVIRONMENTAL HEALTH DEPARTMEN <br /> ` 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Ha+hm-f MIN <br /> i Facility Address: Service Request#: <br /> 330 W. opmmo. LNo0So2,4S <br /> Onsite Service Technician's Name: ICC /Installer Certiric *on#: Manufacturer Training: <br /> Nuc - l�►�( 5 ti,-0 V� CL� k1,01 <br /> SERVICE SERVICE <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ElElelectronic Serial #: y <br /> ❑ Caldwell System El Other <br /> ❑ line testro rammed <br /> P g <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 <br /> El positive shutdown Model: ElPrima p piping testing at: <br /> si <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor <br /> ❑ <br /> El shutdown Model: ElSecon Secondary piping testing at: <br /> si <br /> ❑ fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC s Piping <br /> El fail safe Serial#: ( ) p <br /> El NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> ja1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> W VLKA W, ie% %macs.-s <br /> EHD 23-04 <br /> 1/3/07 <br />