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SAN JOAQUIN COUNTY <br /> ENVFRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA.95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TST PROGRAM SERVICE QUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> I�S(A (0 1 '3106? <br /> Facility Address: Service Request#: <br /> 1501 56,9,00 5' <br /> Onsite Service Technician's Name: ICC Service hnician/Installer Certification#: Manufacturer Traininw.: <br /> to 4 wJ 0 (z sus�as z U t 741 1(0 S 1�- <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ® ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line testroammed <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 proyarnmed <br /> sensor Primary piping testing at: / <br /> ® ❑ positive shutdown Model: psi j g l V ✓tk <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes Ina► <br /> sensor Secondary piping testing at: <br /> ® ❑ positive shutdown Model: ❑ psi <br /> 11 fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: p 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 /> {�S T <br /> wvs <br /> w C, <br /> THIS FACILITY IS SUBJECT TO REIN PECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect : R ived By: Title: <br /> 11M I <br /> `, <br /> EHD 23-04 <br /> Rev 06/29/07 <br />