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RQu l ly <br />�o.• :... •,co SAN JOAQUIN COUNTY 40 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N. 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />hio <br />Facility Name: a <br />L /5+Dr6 <br />Inspection Date: <br />-- L, <br />Facility Address: <br />360 Wes+ � <br />Service Request #: <br />2 <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />6 -7 -XI s <br />Manufacturer Training: <br />SERVICE <br />�� it /•1 X11' �" _ •/ ,,' �. L <br />Leak detector <br />❑ <br />- echanical Model: VAIll q.c[ <br />❑ <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed rn <br />Leak detector + <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />Ar This UST facility is APPROVED to operate <br />SERVICE <br />�� it /•1 X11' �" _ •/ ,,' �. L <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />® <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 NOT APPROVED to operate <br />PAM ► 1'. .i� Ili Fl .0 " ' - W, 0. - e <br />�� it /•1 X11' �" _ •/ ,,' �. L <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />