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°ARUtN °o� SAN JOAQUIN COUNTY <br />c F Za ENVIRONMENTAL HEALTH DEPARTMENT <br />W:, : x <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.orq/ehd <br />Q�ilio <br />Facility Name: <br />Inspection Date: <br />1iG� v <br />Facility Address: <br />Service Request #: <br />4i 1-4 <br />Onsite Service Technician's Name: <br />[CC Serviccey Technician�xp. Date: <br />Manufacturer Trai(fning:�f <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />Received B1- <br />❑ fail safe Serial #: <br />❑ NA <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 />❑ 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 />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />�l�f�Li�ai� r•: <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />Received B1- <br />UDC(s) _ Piping <br />Sump(s) LIST(s) <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° containment component are required to be tested upon <br />installation, 6 months after, and every 36 months therea er. <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 23-04-11 <br />UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />s i ini�.�'•f�ir7c.ur�Y <br />V ��rJ��9 <br />�l�f�Li�ai� r•: <br />i <br />t <br />1. l ova Ir, l 1 <br />114 "6&111.1111101:10 1111111101:4 =1 <br />Received B1- <br />EHD 23-04-11 <br />UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />