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PQUIM <br />�o - • coG SAN JOAQUIN COUNTY <br />N ?< NVIRONMENTAL HEALTH DEPARTMEN <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /g ehd <br />�<<F OKE` <br />Facility Name: <br />Spill bucket ❑ minimum 5 gallon <br />Inspection Date:Vtt_ <br />^I <br />Y� -- c," <br />ttiX f.� <br />Facility Address: <br />Spill bucket ❑ minimum 5 gallon <br />Service Request #: <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />%&579.5 <br />❑ <br />Onsite Service Technician's Name: <br />ICC Service Technician/installer Exp. Date: <br />Manufacturer Training: <br />psi <br />❑ line test programmed <br />L�- <br />sensor <br />i <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Primary piping testing at: <br />❑ electronic Serial #: <br />psi <br />❑ line test programmed <br />minutes <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />UDC(s) Piping <br />❑ fail safe Serial #: <br />Sump(s) UST(s) <br />❑ NA <br />Testing for the above components are next due by: <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />❑ fail safe. Serial #: <br />Cold start of monitoring panel <br />❑ NA <br />Corrosion protection <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />tube with mechanical overfill at 95% <br />UElDrop <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />❑ This UST facility is NOT APPROVED to operate <br />��rn� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />I <br />❑ Caldwell System ❑ Other <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 />Ole <br />Testing for the above components are next due by: <br />®— I <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 />��rn� <br />rr <br />��fi��[±1�r��a► �'��ir�-.�,ri� <br />rsl��i�■Esrr�ar��� <br />I <br />0 !MIM <br />I� <br />Ole <br />NO <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />