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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />`,...: <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj_gov.org/ehd <br />Facility Name: <br />Inspection Date: <br />c z fisZol <br />ZI <br />Facility Address: <br />Servide Requ st #: <br />L4 <br />MfOl S. 61 Dordlao <br />9 R(:) c) Wo I <br />Onsite Service Technician's Name: <br />ICC Service Tech nicianllnstaller Exp. Date: <br />Manufacturer Training: <br />® 11ra <br />a /7 / <br />&ti40 Oa O7 a <br />SERVICE <br />!i • ' <br />Leak detector <br />❑ <br />❑ mechanical Model <br />❑ electronic Serial #: <br />i <br />r� <br />1 , <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 />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />!i • ' <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell. System ❑ Other <br />i <br />r� <br />1 , <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />yWA <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secon ary containment testing for: <br />31qUDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />Note: Please be aware that 21 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 ®»Yer I V1 tuWl <br />►i This UST facility is NOTAPPROVED to opera" <br />r + ' r ,. <br />!i • ' <br />r <br />• • wwffalM♦W <br />i <br />r� <br />1 , <br />_. •. <br />yWA <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br />EHD Inspector: <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />