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? ' 9 SAN JOAQUIN COUNTY <br />• .c <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />. a • • - • '3i17�•7r7:7_1►WAM[•l�Z• 11`+'�rI'►E•�:7x•��[•7.�:7�Z•7:�1 <br />Facility Name: <br />Inspection Date: <br />Leak detector <br />1 <br />Facility Address: UService <br />//' /✓ . <br />Req est #: <br />Onsite Service Technician's Name:ICC <br />Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />I <br />11 / <br />l( <br />SERVICE <br />all <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPELjMPvj,'j1.j&711 --rIME AT EHDS CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />positive shut own odel: 330,21Z-0 <br />fail safe �� Serial #: <br />NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />This UST facility is APPROVED to operate <br />SERVICE <br />all <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPELjMPvj,'j1.j&711 --rIME AT EHDS CURRENT HOURLY RATE. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° containment components are 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 />1 1 <br />all <br />� �' nil/ +� • �. �Y" � 3 ,, <br />PWW <br />THIS FACILITY IS SUBJECT TO REINSPELjMPvj,'j1.j&711 --rIME AT EHDS CURRENT HOURLY RATE. <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />