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AqurN <br />SAN JOAQUIN COUNTY <br />*NVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />F. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />ca�ik0R"`�P <br />Facility Name: <br />%ek <br />Inspection Date: <br />14A (�,� Rlryl,-1�6a2�-_ <br />- <br />7- ® t,5-15 <br />Facility Address: <br />THIS FACILITY IS SUBJECT TO REINSPECTION ATA E AT EHD'S CURRENT HOURLY RATE. <br />Service Request #: <br />—73-73 <br />Leak detector <br />06)1k; '7 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ line test programmed <br />sensor <br />❑ <br />SERVICE <br />%ek <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION ATA E AT EHD'S 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 />❑ <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 />❑ <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 />%ek <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION ATA E AT EHD'S 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 />_42-®P Sump(s) UST(s) <br />-Testing for the above components are next due by: <br />..1 - t <br />Note: Please be aware that 21 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 />r �r <br />%ek <br />THIS FACILITY IS SUBJECT TO REINSPECTION ATA E AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins <br />eceived By <br />Title: <br />EHD 23- UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />