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SAN JOAQUIN COUNTY 10 <br /> INVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgoy.org/ehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE 2UEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Cd <br /> Facility Address: Serviceest#: <br /> ke, CA X46691 <br /> Onsite Service Technician's Name: ICC Service Technician/instiller Certification#: Manufacturer Training: <br /> 12�4 WNLAe�( I)AL11 Wil-113 C�In_: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ® ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test 2roEammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ F-1 electronic Serial#: ]F0-1 ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line testroammed <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ ❑ positive shutdown Model: ® Secondary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: ( ) p g <br /> ❑ NA sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) Other: see below 2,2k- <br /> e 4I <br /> pia <br /> THIS FACILITY IS SUBJECT TO REINS TION AT ANY T1 T EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rec iv y: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />