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°A0.u1 °a SAN JOAQUIN COUNTY <br />s. G <br />*ENVIRONMENTAL HEALTH DEPARTMEN <br />,2 <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�•.. _ .r_ Vie• <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siQov.org/ehd <br />a�! F ORS <br />Facility Name: <br />Inspection Date: <br />�- Is <br />Facility Address: <br />Service Request #: <br />Onsite Service Technici 's Name: <br />llsft� <br />ICC Service Technician/ nstaller Exp. Date: <br />-� . f -� <br />Manufacturer Training: �' $9-% <br />r ray-iAN <br />❑ line test programmed <br />❑ <br />SERVICE <br />1� rZrA <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <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 />Drop tube with mechanical overfill at 95% <br />EOverfi:ll <br />prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />SERVICE <br />1� rZrA <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />}�:i 71M k w <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />0 4 AT ANY TIME AT EHDS CURRENT HOURLY RATE. <br />Secondary containmentesti or: <br />UDC(s) Piping <br />Sumps) UST(s) <br />Testing for the above compon nts are next due by: <br />Note: Please be aware that 21 containment components a required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />'FRI <br />1� rZrA <br />1 VMA <br />• r, <br />}�:i 71M k w <br />Rill-.111*40 "ONAW619 <br />0 4 AT ANY TIME AT EHDS CURRENT HOURLY RATE. <br />EHD 23-04 i UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />