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A <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.si2ov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />, cc 2q, zo f i — ur — 4 S S 5Zz ? 6 / <br />Inspection Date: <br />QAC <br />❑ mechanical Model: <br />%I -2--j (o g <br />Facility Address: <br />IMb L-owse <br />A -V -e !MA11�CA <br />Service Request #: <br />C 2(:)d SZ7�1 <br />te Service Technician's Name:C <br />Leak detector <br />IC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />rs — <br />❑ electronic Serial #: <br />g"ZL�ei�gz— U7- <br />1i3 / iZiw/�� <br />SERVICE <br />, cc 2q, zo f i — ur — 4 S S 5Zz ? 6 / <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />v <br />R'ed By: <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 />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />, cc 2q, zo f i — ur — 4 S S 5Zz ? 6 / <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />v <br />R'ed By: <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <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 />/-2 — S"6 UDC(s)/IJ40k Piping <br />Sump(s) UST(s) <br />Cold start of monitoring panel Fall 1Sb UfCi <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />Ckk U - W A) <br />, cc 2q, zo f i — ur — 4 S S 5Zz ? 6 / <br />2�1C�S f-r-c,l LCI�Mmey Gv c19 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Inspector: A '0 ^ <br />v <br />R'ed By: <br />Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />