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RgU. t Iy <br />o • r SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />;P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si oq v_or- /ehd <br />��1FOFtl, <br />• • • ' • • • • <br />Facility Name: <br />�` <br />Inspection Dat ' <br />t , <br />Facility Address: <br />2- ?, 35- ck-;-c _f�OC4��A <br />Service Reque t #: <br />SRX6 9z 5�5_ <br />Onsite Service Technician's Name: <br />BCC Service Technician/Installer Exp. Date: <br />tLogy�4 <br />ManZcrer Trai Ing: <br />d 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: k) <br />psi <br />❑ line test programmed <br />60 minutes <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Secondary containment testing for: <br />❑ fail safe Serial #: <br />UDC(s) Piping <br />❑ NA <br />Sump(s) UST(s) <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />❑ fail safe Serial #: <br />Cold start of monitoring panel <br />❑ NA <br />Corrosion protection <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />WA <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: k) <br />psi <br />IN; N a= <br />60 minutes <br />C <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 />❑ <br />Other: see below <br />This UST facility is NOT APPROVED to operate <br />EHD 23-04 //11 // <br />Rev 4/30/1 kv Ll/ <br />UST SERVICE REQUEST INSPECTION REPORT <br />WA <br />A <br />'AF <br />IN; N a= <br />EHD 23-04 //11 // <br />Rev 4/30/1 kv Ll/ <br />UST SERVICE REQUEST INSPECTION REPORT <br />