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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />W: x <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />Facility Name: <br />QV -d <br />Inspection Date: <br />4oll <br />I oxm 1 -1 1 1 (' <br />Facility Address: <br />Service Request #: <br />&) <br />El mechanical Model: <br />Onsite Service Tech pician'sName: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />IrP <br />'1-110 WIIA-yd <br />LL22ilq -Wr <br />b <br />SERVICE <br />-I!wjA Mang rum <br />Leak detector <br />E] <br />El mechanical Model: <br />0 electronic Serial #: <br />THIS FACILITY IS SUBJECT <br />0 line test programmed <br />El <br />Leak detector <br />El <br />0 mechanical Model: <br />• electronic Serial #: <br />El <br />0 line test programmed <br />Leak detector <br />El <br />0 mechanical Model: <br />El <br />• electronic Serial #: <br />El line test programmed <br />sensor <br />El <br />El positive shutdown Model: <br />El fail safe Serial #: <br />El <br />0 NA <br />sensor <br />❑ <br />El positive shutdown Model: <br />El <br />0 fail safe Serial #: <br />�L <br />El NA <br />sensor <br />0 <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />El NA <br />El <br />Drop tube with mechanical overfill at 95% <br />F-1 <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />-I!wjA Mang rum <br />Spill bucket 0 minimum 5 gallon <br />El <br />11 1 hour hydrostatic 0 Incon TS -STS <br />• Caldwell System El Other <br />THIS FACILITY IS SUBJECT <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />• Caldwell System 0 Other <br />- Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />F] Caldwell System El Other <br />Primary piping testing at: <br />El <br />DS1 <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(s) <br />El <br />Testing for the above components are next due by: <br />Note: Please be aware that 2* containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />�L <br />Other: see below <br />rd M W 9 =71 3 ri <br />-I!wjA Mang rum <br />P W <br />�tw HEAWA = 2 a M Z i M <br />I <br />W, <br />a, "M1%T�z11W9 TV I <br />THIS FACILITY IS SUBJECT <br />z <br />&�MIIIIIIIIIIMW <br />0m <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11117//08 <br />