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°Aau'M' �• o SAN JOAQUIN COUNTY e { ENVIRONMENTAL HEALTH DEPARTMEN 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ❑ mechanical Model: Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd Onsite Service Tech ician' Name: �f:il milk F10 Facility Name: K— Inspection Date: — — Facility Address: ❑ mechanical Model: Service Request #: 6S R Onsite Service Tech ician' Name: ICC Servicef Tec nician/installer Exp. Date: Manufacturer Training: SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ 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 1XI 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 LIS 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 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS EHD Inspector: ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(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 1XI Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 A UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 Elm 1. •loili ON:. 11. 1 1 4 EHD Inspector: EHD 23-04 A UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12