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Facility Name: Inspection Date: <br /> fL <br /> QIA <br /> Facility Address: <br /> • ._: x •. Manufacturer <br /> _2*51 <br /> I.J / <br /> UTH61 SERVICE <br /> Leak detector <br /> Spillbucket ■ minimum 5 gallon <br /> Model:■ <br /> ■ ■ ■ 1 houri • ■ Incon <br /> b4lectronic Serial 0 Caldwell System 0 Other <br /> ■ - • .•rammed <br /> detector <br /> Spill bucket 0 minimum 5 gallon <br /> ■ mechanical Model: <br /> 0 e[qctronic Serial#: 0 1 hour hydrostatic 0 Incon TS-STS <br /> ■ Caldwell System 0 Other <br /> ■ line tepLogrammed <br /> Leak detector <br /> pill bucket ■ minimum 5 gallon <br /> ■ .: Model: <br /> 0 electronic Serial#: N 0 1 hour hydrostatic 0 Incon TS-STS <br /> ■ Other <br /> ■ - • •• • <br /> sensor Primary piping - • <br /> 0 positive shutdown Model: <br /> si <br /> fail - <br /> ■ • <br /> Serial#: minutes <br /> ■ NA <br /> Secondary containment testing for: <br /> UDC(s) Piping <br /> ■ r • <br /> ■ x <br /> sensor Testing for the above components are next due by: <br /> 0 positive shutdown Model: <br /> ■ fail safe Serial <br /> installation,6 months after,and every 36 months thereafter. <br /> Drop tube with mechanicaloverfill at 95% ►.brawon.;i • • • • •. -. <br /> Drop tube with mechanical overfill at 95% Co rosion protection <br /> Overfill prevention see LG letter 150-1) Other: see below <br /> w <br /> � � + /►� it _ . _ : /� <br /> f - -44Z 11 d [0111 V Ik <br /> EHD in <br />