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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3d 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 Da e; <br /> C, rz Dti <br /> Facility Address: Service Request#: <br /> ? P`4c ) i& S /Z 6 0(-j `7 cl- <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> une , <br /> SERVICE SERVICE <br /> Leak detector PLLC) Spill bucket R minimum 5 gallon <br /> F1 mechanical Model: V-1194 El 0 1 hour hydrostatic 0 Incon TS-STS <br /> ;K electronic Serial#:GC s a JW-,o 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El R mechanical Model: El 0 1 hour hydrostatic El Incon TS-STS <br /> R electronic Serial#: 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> I Leak detector Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: ❑ 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> sensor Primary piping testing at: <br /> ❑ 0 positive shutdown Model: ❑ psi <br /> 0 fail safe Serial#: <br /> 0 NA minutes <br /> sensor Secondary piping testing at: <br /> F-1 El positive shutdown Model: ❑ psi <br /> El fail safe Serial#: minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> 0 0 positive shutdown Model: El UDC(s) Piping <br /> El fail safe Serial#: <br /> 0 Sump(s) UST(s) <br /> El NA <br /> 0 Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) '39r, Other: see below <br /> qCO4 Ve eb C g,_ P1 0&6"l <br /> A&A PLLI4--ej-(-Rr4g., A4&4?a U IM, Be' J46 �ee'j-6 <br /> N-P; VJqVV InVO S�iJIP-JO-J A,(A . j� -7 4-eC$1 <br /> L 4- vL, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> EHD Inspector: Rece' By: Title- <br /> A <br /> EHD 23-04 <br /> 1/3/07 <br />