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0 SAN JOAQUIN 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.sigoy.oreh <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />--? — <br />Eu <br />Facility Address: Service Request #: <br />-213 2,0 Li <br />Onsite Service Technician's Name: [CC Service Tecfinician/installer Certification #: Manufacturer Training: <br />t11V% 1 -1 1'/ 1 X-, 990.9 1 1 )12- t 4- x- K h,--,> <br />Leak detector <br />❑ 13 mechanical Model: <br />0 electronic Serial #: <br />0 line test 2roffammed <br />Leak detector <br />❑ El mechanical Model: <br />0 electronic Serial <br />0 line test 2royammed <br />. Leak detector <br />F-1 mechanical Model: <br />El electronic Serial <br />El line test proEammed <br />sensor <br />El 0 positive shutdown Model: <br />El fail safe Serial <br />El NA <br />sensor <br />❑ 0 positive shutdown Model: <br />0 fail safe Serial #: <br />--j D -NA <br />sensor <br />❑ F-1 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 />1:11 Overfill prevention (see LG letter 150-1) <br />EHD 23-04 <br />Rev 06/22/07 <br />- Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System n Other <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic 0 Incon TS -STS <br />F-1 Caldwell System El 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 />It -914, <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />0 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />