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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 Fax.- (209) 468-3433 Web: wwwsjgoy.org�eh <br />UNDERGROUND STORAGE TANK gIST I PROGRAM SERVICE UEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Fafility Address: �— Service Re nest T � .0 / <br />Lf <br />Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />N <br />4Val <br />L <br />SERVICE SERVICE <br />EHD 23-04 <br />Rev 06/22/07 <br />Leak detector <br />0 <br />El mechanical Model: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System 0 Other <br />0 line test projEarrimed <br />— Spill bucket 0 minimum 5 gallon <br />Leak detector <br />0 <br />0 mechanical Model: <br />n Caldwell System 0 Other <br />0 electronic Serial <br />Spill bucket 0 minimum 5 gallon <br />0 line test proyammed <br />0 1 hour hydrostatic 0 Incon TS -STS <br />. Leak detector <br />❑ <br />0 mechanical Model: <br />Primary piping testing at: <br />0 electronic Serial #: <br />psi <br />0 line test progarnmed <br />minutes <br />2�7 ns, -4, sensor <br />0 positive shutdown Model: <br />Secondary piping testing at: <br />9 fail safe Serial <br />psi <br />0 NA <br />minutes <br />sensor <br />Secondary containment repairs for: <br />0 positive shutdown Model: <br />UDC(s) Piping <br />0 fail safe Serial <br />Sump(s) UST(s) <br />DNA <br />Cold start of monitoring panel <br />sensor <br />Corrosion protection <br />0 positive shutdown Model: <br />Other: see below <br />0 fail safe Serial #: <br />1:1 NA <br />0 <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />EHD 23-04 <br />Rev 06/22/07 <br />Spill bucket El minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />0 Caldwell System 0 Other <br />— Spill bucket 0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic 0 Incon TS -STS <br />n 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 0 Other <br />Primary piping testing at: <br />❑ <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 />0 <br />Corrosion protection <br />0 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />EHD 23-04 <br />Rev 06/22/07 <br />