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SAN JOAQUIN COUNTY <br />N. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />.......... <br />0 <br />Facility Name, <br />A Ig 4(30 <br />I r <br />Inspection Date: <br />'? C) /Zoo <br />El <br />El mechanical Model: <br />Facility Address -01 -1% <br />Wa <br />Service Request #: <br />Is r 040� <br />rUii Service Technician's Name: <br />1( 1 <br />C�a <br />Leak detector <br />ICC Service Technician/Installer ll Date: <br />�-2 00�_ I % — <br />2 1//WZC I 1 <br />Manufacturer Training: - <br />`0,�l <br />1 Z�6 -q 0 <br />E] electronic Serial #: <br />_50 L2 I <br />. 9f - <br />IMI <br />SERVICE <br />Leak detector <br />El <br />El mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />El <br />Leak detector <br />El <br />0 mechanical Model: <br />E] electronic Serial #: <br />El <br />0 line test pro2rammed <br />Leak detector <br />0 <br />0 mechanical Model: <br />El <br />0 electronic Serial #: <br />0 line test programmed <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />El <br />0 NA <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />El <br />0 NA <br />El <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 NA <br />Fj <br />Drop tube with mechanical overfill at 95% <br />F -I <br />Drop tube with mechanical overfill at 95% <br />M <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />— Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />El 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System El Other <br />- Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System F71 Other <br />Primary piping testing at: <br />El <br />Psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(s) <br />El <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 />Cold start of monitoring panezv/j -rs too D <br />El <br />Corrosion protection <br />El <br />Other: see below <br />EHD 23-04 <br />Rev 11/17//08 <br />ir I <br />ell, 7— <br />........... .................... L <br />UST SERVICE REQUEST INSPECTION REPORT <br />M 0 M71 r1d WA <br />KIM <br />E AT EHD'S CURRENT HOURLY RATE. <br />Received 0% <br />EHD 23-04 <br />Rev 11/17//08 <br />ir I <br />ell, 7— <br />........... .................... L <br />UST SERVICE REQUEST INSPECTION REPORT <br />