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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax,(209)468-3433 Web:www.sj2ov.or ehd <br /> UNDERGROUND STORAGE T (UST) PROGRAM SERVICE QUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> I, ,0 r Athi V-- WeiGtr. 5I-oo <br /> Onsite Service Technician's Name: ICC Service Technician/Installer 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 proEammed <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 /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ® ❑ positive shutdown Model: ❑ psi <br /> F-1failsafe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: SOU UDC(s) Piping " <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <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 <br /> !) f TV W i QS re Cj+- SIh4, U PQ 1 <br /> M W 47vQ N U$ L -- i iln, Q, rr%v1 /t col" <br /> P4 Q l f erg i F— 'l <br /> la un fl) VI 1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION Y TIME AT EHDIS CURRENT HOURLY RATE. <br /> EHD hi ector: Receiv y Ti le: <br /> 2CvJtntl <br /> EHD 23-04 <br /> Rev 06/22/07 <br />