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oUf F.. �oG SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 `p.• Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.se_ov.org/ehd A��FOR� Facility Name: Inspection Date - co hanical Model: el Facility Address: THIS • • HOURLY RATE. Service Request #. ❑ Leak detector ❑ Onsite Service Technician' ame: ICC Service Technician/installer Exp. Date: Manufacturer Training: ❑ line test programmed 1-111:-D i 1 SERVICE Leak detector ❑ hanical Model: el tronic Serial #: I-10 1 THIS • • HOURLY RATE. ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other THIS • • HOURLY RATE. Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) LIST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate 1MIFrim THIS • • HOURLY RATE. MAW,r.` C/ v EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10