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tcL <br />�o -coG SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMEN <br />W X <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />q ;P • Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sdgov.org/ehd <br />FoR� <br />Facility Name: <br />Inspection Date: <br />- <br />Facility Addr ss: <br />k <br />Service Request #: <br />si 2 Service echn'cian' Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />echanical Model: <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />electronic Serial #: 711 _ <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 />Cold start of monitoring panel <br />❑ fail safe Serial #: <br />Corrosion protection <br />❑ NA <br />Other: see below <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 />I,IIIIII•• -I,III I Iir <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 />EHD Inspector: <br />minutes <br />Re c ived By: <br />Secondary containment testing for: <br />UDC(s) Piping <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 />I,IIIIII•• -I,III I Iir <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />THIS F <br />ILITY IS SUBJECT TO REINSPECTION T ANY TIME AT END'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />Re c ived By: <br />Title <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />