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�oAQuly ••Co SAN JOAQUIN COUNTY Facility Address: 1 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 ❑ mechanical Model: Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sugov.org/ehd ��1FOK� ICC Service Technician/Installer Exp. Date: Facility Name: Z,1'3'3 Inspection Date: Facility Address: 1 Service Request #: ❑ mechanical Model: Onsite Service Tec nician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Tr inin I j ' 3 0 %�_ ( j ti SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed 0 Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ 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% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket Nftinimum 5 gallon 0 4'1hour 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 operate EHD 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT x YRAVIrkfff 0 EHD 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT