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SAN JOAQUiN COUNTY 0 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.ora/ehd Facility Name: +�r_1 CILIX Inspection Date: ❑ ❑ mechanical Model: Facility Address: Service Request #: Onsite Service Technician's Name: ICC Servic - Techniri Wlnstaller Exp. Date: Manufacturer Training: ❑ mechanical Model: 2Z7. f' SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #` ❑ ❑ line test programmed Reoived By: sensor positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ 47/ sensor ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ 6,"t_ 4phw o. -sensor ` ❑ positive shutdown Model ®� ❑ fail safe Serial #: NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS 1 *WE MOWa I �. o e ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi Reoived By: minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 (✓ Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT s X37:--„` _ �.—•r= 1 *WE MOWa I �. o e 11 Reoived By: Title: EHD 23-04 (✓ Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT