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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMAN <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgpy.org�ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE QUESTINSPECTION REPORT <br />Facillt Na c: Inspection Date: <br />ki WW*4 Nto(w -N-08 <br />Facility Address: Service Request #: <br />A <br />S�-OD 15LtIll <br />Onsite Service Technician's Name: ICC Service Technician/installer Certification Manufacturer Training: <br />SERVICE <br />Leak detecto11r <br />Spill bucket El minimum 5 gallon <br />El mechanical Model: <br />0 1 hour hydrostatic El Incon TS -STS <br />electronic Serial #: 4�& <br />0 Caldwell System F-1 Other <br />0 line test pro ned'Sa 14--7C 0[1_ <br />Spill bucket [I minimum 5 gallon <br />Leak detector <br />F-1 I hour hydrostatic El Incon TS -STS <br />El mechanical Model: <br />0 Caldwell System 0 Other <br />electronic Serial <br />Spill bucket 0 minimum 5 gallon <br />line test programme- d <br />0 1 hour hydrostatic 0 Incon TS -STS <br />-E1 <br />. Leak detector <br />■ <br />El mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial <br />psi - <br />0 line test programmed <br />minutes <br />sensor <br />■ <br />El positive shutdown Model: <br />psi <br />0 fail safe Serial #: <br />minutes <br />E■ -1 NA <br />Secondary containment repairs for: <br />sensor <br />UDC(s) Piping <br />0 positive shutdown Model: <br />Sump(s) UST(s) <br />1 11 fail safe Serial #: <br />Cold start of monitoring panel <br />El NA <br />Corrosion protection <br />sensor <br />■ <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />El NA <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />K97 M -n I a mon <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />F-1 <br />0 1 hour hydrostatic El Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT Ali TIME AT EHD'S CURRENT HOURLY RATE. <br />0 Caldwell System F-1 Other <br />Spill bucket [I minimum 5 gallon <br />0 <br />F-1 I hour hydrostatic El Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 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 />7 <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />F-1 <br />Other: see below <br />11 W.1 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT Ali TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD 23-04 <br />Rev 06/22/07 <br />