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SAN JOA UIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax (209)468-3433 Web:www.sisov.or /U ehd <br /> UNDERGROUND STORAGE TAN S ) PROGRAM SERVICE "QUEST S C N REPORT <br /> Facility Name: Inspection Date: <br /> f <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Techniciantinstalier Certification#: Manufacturer Training: . <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ® electronicmechanical <br /> thanial ModelSerial : ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ❑ Caldwell System ❑ Other <br /> . Leak detector Spill bucket ❑ minimum 5 gallon <br /> ® ❑ mechanicalModel: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdownModel: <br /> ® ❑ fail safe Serial : ® psi <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ psi <br /> positive shutdown Model:® ❑ fail safe Serial#: ® mi <br /> ❑ A nutes <br /> sensor Secondary contairiment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UC(s) Piping <br /> ❑ fail safe Serial <br /> 13A Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ op tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 <br />