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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENTF <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.or ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE R QUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facile V Address: Service Request #: <br />flow, 42f �,j <br />onp. Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />1113 K 10W f 0.4q 4,'yl fiA& <br />I <br />WZLIM <br />SERVICE <br />Leak detector <br />■ <br />El mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />[I electronic Serial #: <br />0 Caldwell System El Other <br />El line test programmed <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />■ <br />0 mechanical Model: <br />F-1 Caldwell System 0 Other <br />El electronic Serial #: <br />- Spill bucket 0 minimum 5 gallon <br />El line test programmed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />Leak detector <br />0 Caldwell System n Other <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 />0 fail safe Serial #: <br />minutes <br />EINA <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />■ <br />Cold start of monitoring panel <br />■ <br />protection <br />sensor <br />Other: see below <br />• positive shutdown Model: <br />• fail safe Serial #: <br />■ t L <br />Drop tube with mechanical overfill at 95% <br />WZLIM <br />SERVICE <br />F W/A W.Fff <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System El Other <br />it 1071, 911 MA J W55 AM W-M&M,� <br />Spill bucket 0 minimum 5 gallon <br />1:1 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />F-1 Caldwell System 0 Other <br />- Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System n Other <br />Primary piping testing at: <br />El <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 />0 <br />Cold start of monitoring panel <br />protection <br />rCorrosion <br />EE -J] <br />Other: see below <br />I - V <br />EHD 23-04 <br />Rev 06/22/07 <br />F W/A W.Fff <br />yu) tit <br />I <br />KPATA <br />it 1071, 911 MA J W55 AM W-M&M,� <br />��� <br />I - V <br />EHD 23-04 <br />Rev 06/22/07 <br />