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�QP'QU!N •.CQ .� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N I X 600 East Main Street, Stockton, CA 95202-3029 • ;� Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj oq v_orQ/ehd Facility Name: Inspection ate: Facility Address: Service Request #: t� Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: Leak detector ❑ SERVICE , r . �� . al .s ,�Arli i . � . /�+� 1WN 22MIIIIIIIII 11111 -56 eak detector O% -mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑Corrosion 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) Ck This UST facility is APPROVED to operate SERVICE , r . �� . al .s ,�Arli i . � . /�+� 1WN 22MIIIIIIIII 11111 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 ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi 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 2° 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 mm Wirty"W171-09011111111`4114. , r . �� . al .s ,�Arli i . � . /�+� 1WN 22MIIIIIIIII 11111 WE I�VFWWUIWA VIM= r EHD 23-04 Rev 10/06/10 V / r UST SERVICE REQUEST INSPECTION REPORT