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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fare:(209)468-3433 Web:www.sigov.or ehd <br /> UNDERGROUND STORAGE TAN (UST) ROGRAM SERVICE QUEST INSPECTION REPORT <br /> Facility Name: Inspectiott Date,• <br /> Facility Addresk <br /> ` <br /> --I �^ Service Request##: .7 <br /> �7 <br /> Onsite Service Technician's Name: IC Service Technician/Installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 11minimum 5 gallon <br /> mechanical Model: kir-11:7 '2-j> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test pro ammed <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 pro ammed <br /> ensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ® psi <br /> fail safe Serial #: '71 310 <br /> minutes <br /> ❑ NA <br /> 1 ' _ ensor Secondary piping testing at: <br /> positive shutdown Model: ❑ psi <br /> ail safe Serial#: � l 5'30 <br /> �I���TTT� minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ 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 /> ra-tu <br /> fi 1 <br /> ' �� ��ss�e- 6 t — C— -f s <br /> THIS FA ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT E4-11)t CURRENT HOURLY RATE. <br /> EHD(nspecto Received By: � � Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />