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R�tN <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />1868 East Hazelton. Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />ORS <br />Facility Name: <br />Inspection Date: <br />IZ <br />13 <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />��• l <br />❑ electronic Serial #: <br />Facility Address: / <br />IVa <br />�` <br />Service Request #: <br />P <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />Onsite Service echnician's Name: <br />ICC S rvice Technicianlinsta ler Exp. Date: <br />" <br />Manufacturer Training: <br />1113 <br />kA ►: <br />i <br />❑ fail safe Serial #: <br />o t <br />SERVICE <br />Leak detector <br />mechanical Model: -zC C z <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />��• l <br />❑ electronic Serial #: <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 />T IS FA <br />❑ fail safe Serial #: <br />T EHD'S CURRENT HOURLY RATE. <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 />This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />��• l <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 />T IS FA <br />UDC(s) Piping <br />T EHD'S CURRENT HOURLY RATE. <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° 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 />EHD 23-04 <br />Rev 4/30/1 <br />UST SERVICE REQUEST INSPECTION REPORT <br />��• l <br />T IS FA <br />ITY IS SUBJECT TO REINSPE N'AT ANY I <br />T EHD'S CURRENT HOURLY RATE. <br />EHD lnsPA6tol, <br />Rec ved byi VTitle: <br />EHD 23-04 <br />Rev 4/30/1 <br />UST SERVICE REQUEST INSPECTION REPORT <br />