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SAN JOAQUIN COUNTY �/ - - -- <br />ENVIRONMENTAL HEALTH DEPARTMENIN <br />304 East Weber Avenue, 3d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />.. T.,v r irTQ9M nnnruAM cFRVIrF. RROTTEST INSPECTION REPORT <br />-- <br />Facility Name: <br />Inspectionate: <br />-7 [b--7 <br />USA AS0 line, <br />#(10 <br />2- <br />Facility Address: <br />2132 AAAA I <br />4vc 404 l <br />Service Request #: <br />390t)Lc qY <br />Onsite Service Technician's Name: <br />ICC Service Technician/installer Certification #: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />FVAEWA�NWW, - <br />SERVICE <br />/ O q" Sup 1 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />EHD Inspec V I/ + <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />151 sensor M (W <br />positive shutdown Model: 2 0 <br />❑ <br />❑ fail safe Serial #: <br />11 NA (03325 <br />sensor 'Tur h<_ <br />❑ <br />positive shutdown Model: -200 <br />❑ fail safe Serial #: & 30�12.3 <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />SERVICE <br />/ O q" Sup 1 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />EHD Inspec V I/ + <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ hlcon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />, <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 />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />VOJ ri I l/P1li Io^A I <br />/ O q" Sup 1 <br />�Q /t SegorS A.1 <br />►� � wt� l 1 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspec V I/ + <br />Received <br />Title: <br />EHD 23-04 <br />1/3/07 <br />