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4 SAN JOAQUIN COUNTY th <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sijZov.org/eh <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection te: <br />Facility Address: <br />N� piCC,��i 2p s c,�� <br />Service Request #: <br />Onsite Service Technician's Name: <br />ASA L056 <br />ICC Service Technician/Installe Certification #: <br />tj 11 0 3 Z g i or, <br />Manufacturer Training: <br />oAv.-) 110-71441 <br />SERVICE <br />�•flj4t M1L r.. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSP§IqTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />R iv 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 />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />XCorrosion <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 />�•flj4t M1L r.. <br />NOCA-Spill bucket )1 minimum 5 gallon <br />Cl� s y iGrrt 14 0-11 <br />k11WAa <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSP§IqTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System )4 Other <br />R iv 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 />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />XCorrosion <br />protection If 'O &8A lArL. <br />❑ <br />Other: see below <br />S i er r� t" � n 0.1 �`¢ W <br />�•flj4t M1L r.. <br />(/ (9 �` <br />Cl� s y iGrrt 14 0-11 <br />k11WAa <br />C-11 <br />THIS FACILITY IS SUBJECT TO REINSP§IqTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD ector: <br />Unl Flue.,, <br />R iv By: <br />Title: <br />EHD 23-04 <br />Rev 06/22/07 <br />43 <br />