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El <br />E <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Maln,Street, Stockton, CA 95202-3029 <br />Telephorre. (209) 468.3420 Fax. (209) 468-3433 Web: w—WW.sjgov.otg/ehd <br />V. J k L LIPS :4 401114111 a 11i't-ti-MAj Esm I a4gel-n <br />Facility Name: <br />Inspection Date, <br />Leak detector <br />El <br />Facility Address: <br />Service Requedt <br />D electronic Serial #: <br />onsite Service Tachniclatfs Home: 1cr. service Tifthnician/IneWler Exp. Date: <br />Manufacturer Training: <br />> :z - <br />El <br />SERVICE <br />Leak detector <br />El <br />El mechanical Model: <br />D electronic Serial #: <br />D line test programmed <br />❑ <br />Leak detector <br />El <br />0 mechanical Model: <br />0 electronic Serial #: <br />❑ <br />0 line test programmed <br />We: <br />sensor <br />❑ <br />0 positive shutdown Model: <br />0 fall safe Serial #: <br />0 NA <br />sensor <br />ff -positive shutdown Model: <br />❑ <br />0 fall safe Serial <br />❑ <br />[I NA <br />sensor <br />❑ <br />El positive shutdown Model: <br />U fail safe Serial #: <br />Q NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />ELI <br />Overfill prevention (see LG letter 150-1) <br />El This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket El minimum 5 gallon <br />❑ <br />111 hour hydrostatic 0 Incon TS -STS <br />[I Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon, <br />❑ <br />0 1 hour hydrostatic 11 ]noon TS -STS; <br />0 Caldwell System Cl Other <br />Primary piping testing at: <br />❑ <br />psi <br />We: <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(S) <br />Testing far the above components are next due by: <br />Note: Pbm be amrs tbet r cor4afnnignt componems are required to be twhid upon <br />Instaflefim, 8 months Mr. and ey" 36 months thmeft. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other. see below <br />D This UST facility Is NOT APPROVED to operate <br />e <br />E'A <br />Ti FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD;S CURRENT HOURLY RATE. <br />Recalve4 <br />We: <br />UST SERVICE REQUEST INSPECTION REPORT <br />EHD'2""' <br />Rev I 0108/10, <br />