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? SAN JOAQUIN COUNTY <br />i ENVIRONMENTAL HEALTH DEPARTMENT <br />;; 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />fct1:0 '4 <br />Facility Name: <br />( S" Ck <br />Inspection Date: <br />��>—al —1 b <br />Facinfy Address: <br />. <br />Service Request #: <br />Onsite Service Technician's Name: <br />icc Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ line test programmed <br />❑ <br />SERVICE <br />i <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />gilt <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />�.� 1 `: �° ��' <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />i <br />Spill bucket ❑ minimum 5 gallon <br />-hour <br />5(1 hydrostatic ❑ Incon TS -STS <br />❑ Cald ell S te 91, Other <br />e <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />w <br />❑ Caldwell System ❑ Other <br />gilt <br />Primary piping testing at: <br />❑ <br />psi <br />�.� 1 `: �° ��' <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 20 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 />LEI <br />Other: see below <br />�7r • APPROVED to operate <br />EHD 23-04 k—/ UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12(�k lvt <br />i <br />rWIW <br />•� \ <br />w <br />a <br />gilt <br />�.� 1 `: �° ��' <br />h�iS�tiiiil/�;rfi►'iii!:�i>�.�J'[�JI��T�r:�.,•��'5.+�►`��f�`L�t\1�,���1 <br />• REINSPECTION AT ANY TIMEAT EHD'SHOURLY <br />Emil <br />EHD 23-04 k—/ UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12(�k lvt <br />