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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEAV <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.siizov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE QUEST INSPECTION REPORT <br />Facility Name: Inspection Dat <br />A <br />4j " 4 5VW 1011161 <br />Facility Addres1s: I Servfce Rquest #: <br />120 )#. Wo 5( <br />Onsite Service Technician's Name: ICC Service Technician/installer Certification #: lyIa fa rr T ramme: aal FIL <br />WNITIMIRIM, al <br />SERVICE <br />Leak detector <br />F-1 <br />El mechanical Model: <br />D I hour hydrostatic D Incon TS -STS <br />El electronic Serial #: <br />D Caldwell System 0 Other <br />El line test programmed <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />El Caldwell System 0 Other <br />0 electronic Serial <br />- Spill bucket 0 minimum 5 gallon <br />0 line test programmed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />. Leak detector <br />❑ <br />0 mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial #: <br />psi <br />0 line test programmed <br />minutes <br />sensor <br />❑ <br />0 positive shutdown Model: <br />psi <br />F-1 fail safe Serial #: <br />minutes <br />El NA <br />Secondary containment repairs for: <br />sensor <br />El <br />0 positive shutdown Model: <br />Sump(s) UST(s) <br />❑ fail safe Serial <br />Cold start of monitoring panel <br />0 NA <br />Corrosion protection <br />sensor <br />El <br />F-1 positive shutdown Model: <br />F-1 fail safe Serial <br />El NA <br />El <br />Drop tube with mechanical overfill at 95% <br />D <br />Drop tube with mechanical overfill at 95% <br />11 <br />Overfill prevention (see LG letter 150-1) J <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />0 <br />D I hour hydrostatic D Incon TS -STS <br />D Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />El I hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />- Spill bucket 0 minimum 5 gallon <br />D <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 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 />0 <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />0 <br />Other: see below <br />IRS MfWNt1jW*1LmKVwW1 71, 7NI �RU <br />W NN ff C- zi <br />EHD 23-04 <br />Rev 06/22/07 <br />EHD 23-04 <br />Rev 06/22/07 <br />