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SAN JOAQUIN COUNTY <br />" IWNVIRONMENTAL HEALTH DEPARTMENT <br />304 t Weber Avenue, 3rd Floor, Stockton, CA 95207- 708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Facility .Name: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: <br />Service Request #: <br />❑ electronic Serial #: 1L 1 11 <br />Received By. 4 <br />~, <br />Onsite Service Technician's Name: <br />[CC Service Technician/ r¢Certi6cation #: <br />Manufacturer Training: <br />� o C,-rr) <br />0 X010 <br />\)(V\L <br />SERVICE <br />t % @ * , C. 0 t T--'4 - 4 �-.- . - C F Ac ( 0 f `l t 0 V-, , R i <br />Leak detector <br />❑ <br />mechanical Model: k U;0'00 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY, (ME AT EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: 1L 1 11 <br />Received By. 4 <br />~, <br />❑ line test programmed <br />❑ <br />Leak detector <br />I mechanical Model: \jt L01 -0\D <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <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 />❑ <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 />SERVICE <br />t % @ * , C. 0 t T--'4 - 4 �-.- . - C F Ac ( 0 f `l t 0 V-, , R i <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY, (ME AT EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Received By. 4 <br />~, <br />—_ Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <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 piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />1 11 im <br />t % @ * , C. 0 t T--'4 - 4 �-.- . - C F Ac ( 0 f `l t 0 V-, , R i <br />j T( �-Q P £.R <br />h > t t,% Ize L '� �, Pkf L A c(--9 <br />PA - <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY, (ME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector. <br />Received By. 4 <br />~, <br />ETt <br />EHD 23-04 <br />1 11 im <br />