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SAN JOAQUIN COUNTY <br />4PENVIRONMENTAL HEALTH DEPARWT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.oreehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />fl,0 <br />IVI 4101 <br />Facility Address: Service Request #: <br />2z4a&tj AIJF , UZICALOIAJ &900 �S'*—UA 2� 9q, <br />Onsite Service Technician's Name: lec Service-rechnician/Initaller Certification #: Manufacturer Training: 7 <br />6A-kLi HAVK19 I 52,4v1ri6o—U7- opw Cs-0 g S; � <br />SERVICE <br />Leak detector <br />❑ <br />El mechanical Model: <br />l hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System 0 Other <br />11 line test progammed <br />Spill bucket 11 minimum 5 gallon <br />Leak detector <br />El <br />0 mechanical Model: <br />El Caldwell System F1 Other <br />0 electronic Serial #: <br />Spill bucket El minimum 5 gallon <br />El line test programmed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />. Leak detector <br />El <br />0 mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial #: <br />psi <br />El line test programmed <br />minutes <br />sensor <br />0 <br />0 positive shutdown Model: <br />psi <br />11 fail safe Serial #: <br />minutes <br />El NA <br />Secondary containment repairs for: <br />sensor <br />❑ <br />El positive shutdown Model: <br />Sump(s) UST(s) <br />El fail safe Serial #: <br />Cold start of monitoring panel <br />El NA <br />Corrosion protection <br />sensor <br />Other: see below <br />0 positive shutdown Model: <br />❑ fail safe Serial #: <br />El NA <br />0 <br />Drop tube with mechanical overfill at 95% <br />El <br />_ Drop tube with mechanical overfill at 95% <br />L 0 -j <br />Overfill prevention (see LG letter 150-1) -j <br />SERVICE <br />Spill bucket Rminimum 5 gallon <br />21 <br />l hour hydrostatic 0 Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYT)ME AT EHD'S CURRENT HOURLY RATE. <br />0 Caldwell System 0 Other <br />Spill bucket 11 minimum 5 gallon <br />El <br />El I hour hydrostatic 0 Incon TS -STS <br />El Caldwell System F1 Other <br />Spill bucket El minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />R Caldwell System 0 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 />0 <br />UDC(s) Piping <br />Sump(s) UST(s) <br />R <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />20 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYT)ME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector <br />EHD 23-04 <br />Rev 06/22/07 <br />