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0 SAN JOAQUIN COUNTY 4 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fur: (209) 468-3433 Web: www.sitov.ork'ehd <br />[JEST INSPECTION REPORT <br />UNDERGROUND STORAGE TANK UST) PROGRAM SERVICE <br />Facility Name: <br />PV3P-& I-/-u(,K-, <br />FacilityAddress: <br />e2(03� 'b0 LIC C�-�� fir, <br />Onsite Service Technician's Name: ICC Service Tech <br />s�oc, lL-�Do <br />vice Request #: <br />#: I Mgnufacturer Training: <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ psi42 <br />minutes 9 t Rn <br />Secondary containment repairs for: <br />UDC(s)Vipin9 <br />Sump(s) <br />.iVe&Aj UST(s) <br />❑ Cold start of monitoring panel <br />❑ Corrosion protection <br />R Other: see below <br />EHO 23-04 <br />Rev 06122I <br />SERVICE <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />vice Request #: <br />#: I Mgnufacturer Training: <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ psi42 <br />minutes 9 t Rn <br />Secondary containment repairs for: <br />UDC(s)Vipin9 <br />Sump(s) <br />.iVe&Aj UST(s) <br />❑ Cold start of monitoring panel <br />❑ Corrosion protection <br />R Other: see below <br />EHO 23-04 <br />Rev 06122I <br />