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SAN JOAQUIN COUNTY <br /> 0 1W <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.orjz/ehd <br /> UNDERGROUND STORAGE TANK QIST) PROGRAM SERVICE QUEST INSPECTION"PORT <br /> Facility Name: Inspection Diate: <br /> C <br /> Facility Address: Service Request#: <br /> Ct 6 �t% 19 Or T,71 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> 0 mechanical Model: -Spill bucket 0 minimum 5 gallon <br /> ❑ 0 electronic Serial #: ❑ 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 line test programmed 0 Caldwell System 0 Other <br /> Leak detector <br /> 0 mechanical Model: -Spill bucket 0 minimum 5 gallon <br /> ❑ 0 electronic Serial#: ❑ 0 1 hour hydrostatic 0 Incon TS-STS <br /> El line test programmed 0 Caldwell System 0 Other <br /> . Leak detector <br /> 0 mechanical Model: -Spill bucket 0 minimum 5 gallon <br /> El F-1 electronic Serial#: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> El line test programmed 0 Caldwell System 0 Other <br /> sensor Primary piping testing at: <br /> ❑ 0 positive shutdown Model: 0 <br /> 0 fail safe Serial#: psi <br /> 11 NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ 0 positive shutdown Model: 0 <br /> D fail safe Serial#: psi <br /> DNA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ 0 positive shutdown Model: 0 UDC(s) Piping <br /> 0 fail safe Serial <br /> 0 NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> 0 Overfill prevention (see LG letter 150-1) Other: see below <br /> vv4q hls�-000,f, 4t r v0,010C <br /> P Li <br /> 6-z AL <br /> e eU�r?&A-L 4&14 0 ItAj- (4 1W r— !LA10A <br /> �A W(,tA M6'1j"r,4 <br /> THIS FACILITY ISSU13JECT TO REINSPECTION Al;ANY TIME AT PHDISCURRENT HOURLY RATE. <br /> E Inspector: ---F <br /> ceived By. t– Title: <br /> <51 <br /> EHD 23-04 <br /> Rev 06/22/07 <br />