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�qPQ U1 N •.co .� SAN JOAQUIN COUNTY if a r�ri ENVIRONMENTAL HEALTH DEPARTMENT •2 N < 600 East Main Street, Stockton, CA 95202-3029 • Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd Facility Name: (l, e Inspection ate• C� Facilit ress: m^ 5 S 1 ' (I nl../+ o /Sh r / Service Request #: S' Onsite Service Technicia 's Name: ICC Se ice Te nician/Installer Exp. Date: III ctur Training: VWja H ❑ line test programmed pq V u SERVICE b 0", X11 ljc 1 �1 .� a � f#4�@AWA ,' i I �R,J�ITI INA•R t oi. ,RMS Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model ❑ electronic Serial #: ❑ ❑ line tes rammed e sor KS tdown Model: ❑ fail safe Serial #: ❑ NA 044 "LEI 4f n s � ❑ 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% E l prevention (see LIS letter 150-1) ❑ This UST facility is APPROVED to operate SERVICE b 0", X11 ljc 1 �1 .� a � f#4�@AWA ,' i I �R,J�ITI INA•R t oi. ,RMS 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 ❑ 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 21 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 •.. To ti NAPA i r► t s• i /. l! b 0", X11 ljc 1 �1 .� a � f#4�@AWA ,' i I �R,J�ITI INA•R t oi. ,RMS EHD 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT