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R ug I. <br />�o.• -.. coG SAN JOAQUIN COUNTY <br />z ENVIRONMENTAL HEALTH DEPARTMENT <br />y ` 600 East Main Street, Stockton, CA 95202-3029 <br />`P.. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />a��FOR� <br />" • ) •11X =1111105032m= <br />Facility Name: <br />Inspection Date: <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT • REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />Facility Address: <br />Service Request #: <br />❑ <br />Leak detector <br />El <br />O 'te Se ice Technicia 's ame: <br />Icc'8erV-icb Tech ician/ nstaller Exp. Date: <br />nufa urer raining: <br />A Mle2Tta <br />6� n <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT • REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />El <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />E] <br />❑ line t st programmed <br />enso <br />positive shutdow `Model: <br />ail safe Serial #: <br />NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />r❑ <br />❑ <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT • REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <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 />E] <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 />Corrosion protection <br />r❑ <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />UM �T%W SO: AWN 111TIZA <br />,��. R/ 5l T u1_ <br />THIS FACILITY IS SUBJECT • REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />��—. <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />