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Rqurk <br />°' eo SAN JOAQUIN COUNTY 41 <br />{ ENVIRONMENTAL HEALTH DEPARTMENT <br />•.aa_ 600 East Main Street, Stockton, CA 95202-3029 <br />`P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s4gov.or /q ehd <br />ail FORS <br />Facility Name: <br />Inspection Date: <br />❑ <br />t— _ <br />Fac ity ddress: <br />Service Request #: <br />❑ Caldwell System ❑ Other <br />❑ line test programmed <br />Onsite Service Technician's Name: ICC Servic6 Technician/installer Exp. Date: <br />Manufacturer Training: <br />12-1- Jaa. r 57_ /-Z,—/ 5 <br />r <br />SERVICE <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ electronic Serial #: <br />❑ Caldwell System ❑ Other <br />❑ line test programmed <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Primary piping testing at: <br />❑ line test programmed <br />psi <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Secondary containment testing for: <br />❑ fail safe Serial #: <br />UDC(s) Piping <br />❑ NA <br />w- - Sump(s) UST(s) <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Testing for the above components are next due by: <br />❑ fail safe Serial #: <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 />❑ NA <br />Cold start of monitoring panel <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Other: see below <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />y. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />TIME AT EHD'S-- • - RATE. <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 />w- - Sump(s) UST(s) <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 />u <br />y. <br />TIME AT EHD'S-- • - RATE. <br />EHD .ect <br />/11,00 <br />of, WE P" <br />OOOP <br />® <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />