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'ogqu I....co <br />_ SAN JOAQUIN COUNTY <br />2� ENVIRONMENTAL HEALTH DEPARTMENT <br />W:_ <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /q ehd <br />Facility Name: <br />��� <br />Inspection Date: <br />I car <br />Facility Add ss: <br />Service Reque t <br />Onsite Service Technician's Name, <br />[CC Service Technician/Installer Exp. Date: <br />Manufacturer Traini <br />AIV -1,412 <br />SERVICE <br />Leak detector �W'� (, <br />❑ <br />mechanical I Model: i/ i `) L2 <br />�� <br />❑ electronic Serial #: l <br />❑ line test programmed <br />❑ <br />Leak detector <br />IRmechanical Model N/I�i <br />❑ electronic Serial #: tt <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <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 />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 />minutes <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 />*_ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br />EHI <br />Re% <br />t' <br />i <br />