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0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />F" M ���_r 4 or, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Pax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />CI �� grla'L. Se rvt�, -- S vt, U� <br />Inspection Date - <br />(Zl v—? <br />Facility Address: <br />S 3 2- N <br />Service Request #: <br />S(zvo5 Diag <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />iFr( L it4u( <br />Oh`�-7- <br />F.-Cpe, 'v VMS <br />SERVICE <br />f -� �tFL.- (aMs <br />01 Leak detector Fe- p_c, d <br />❑ <br />X mechanical Model: S "(P- lte � n <br />-7 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: 060!0 S <br />Received B <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 />Awu 14 r sensor ve tw lLbb <br />❑ <br />❑ positive shutdown Model: D 3 <br />❑ fail safe Serial #: ,,pbL(D <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />f -� �tFL.- (aMs <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 EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Received B <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 />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />'r it v (/a N tiS �✓` <br />f -� �tFL.- (aMs <br />e l cd GG 7""'J O e- Iv / � <br />v— <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: Gid <br />Received B <br />Title: <br />EHD 23-04 <br />1/3/07 <br />