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Rquly <br />SAN JOAQUIN COUNTY 10 <br />:err y .y ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />4�%Fi3R�; <br />Facility Name: <br />Leak detector <br />Inspection Date: <br />.Ikq Tnk�l <br />3 �� aL, tri/► i �/. L.` W Ear <br />0--7- 11 <br />Facility Addre s: <br />VService <br />Re nest #: <br />Onsite Service Technician's Name: <br />❑ <br />ICC Service Technician/Installer Exp. Date: <br />u acturer T' ai g: <br />❑ electronic Serial #: <br />❑ <br />it <br />9.1 <br />This UST facility is APPROVED to operate <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />3 �� aL, tri/► i �/. L.` W Ear <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <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 />9.1 <br />This UST facility is APPROVED to operate <br />❑ This UST facility is NOT APPROVED to operate <br />t r <br />l0,r�: =3 �r►t' M11, ter. .■ 1 1 ^/Y. rVA, <br />bucket ❑ minimum 5 gallon <br />1i <br />FSpill <br />ur hydrostatic ❑ Incon TS -STS <br />3 �� aL, tri/► i �/. L.` W Ear <br />well System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />•�• <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 />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />t r <br />l0,r�: =3 �r►t' M11, ter. .■ 1 1 ^/Y. rVA, <br />1i <br />3 �� aL, tri/► i �/. L.` W Ear <br />9 U73"IF <br />THIS FACILITY IS SUBJECT TOREINSPE99ON• <br />•�• <br />EHD 23-04 r <br />UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />