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of Xull <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />x <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.siaov.org/ehd <br />foldl Polo <br />F plity Name: <br />ILI -70#�� <br />% #- T <br />Inspection Date: <br />t(.05 <br />Facility Address: I <br />Lf61 c-- . I <br />I-- 6VWV 24" C () <br />Service Request #: <br />�*M517iffl <br />ite Se ice Technician's Name: <br />ICC Service Technician/installer Exp. Date: <br />11A It9010 <br />Manufacturer Training: <br />ON Lf -14 AA11 <br />SERVICE <br />d'IM Spill bucket <br />Leak detector <br />❑ <br />El mechanical Model: <br />El Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System <br />11 line test programmed <br />Leak detector <br />0 <br />0 mechanical Model: <br />0 1 hour hydrostatic <br />El electronic Serial #: <br />El line test programmed <br />0 Other <br />Leak detector <br />El <br />0 mechanical Model: <br />0 <br />0 electronic Serial #: <br />El Incon TS -STS <br />0 line test programmed <br />0 Caldwell System <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial <br />Psi <br />0 NA <br />sensor <br />❑ <br />0 positive shutdown Model: <br />Secondary containment testing for: <br />0 fail safe Serial #: <br />UDC(s) <br />DNA <br />sensor <br />El <br />El positive shutdown Model: <br />Testing for the above components are next due by: <br />• fail safe Serial <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 />• NA <br />o <br />Drop tube with mechanical overfill at 95% <br />El <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />SERVICE I <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />d'IM Spill bucket <br />El minimum 5 gallon <br />29 <br />0 1 hour hydrostatic <br />El Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />0 Caldwell System <br />PY Other coym <br />Spill bucket <br />0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic <br />El Incon TS -STS <br />0 Caldwell System <br />0 Other <br />- Spill bucket <br />0 minimum 5 gallon <br />0 <br />0 1 hour hydrostatic <br />El Incon TS -STS <br />0 Caldwell System <br />0 Other <br />Primary piping testing at: <br />11 <br />Psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) <br />Piping <br />Sump(s) <br />LIST(s) <br />❑ <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 />El <br />Cold start of monitoring panel <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />07. CAAMlIM, a NO 1� <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspec r- <br />ZAP4 <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />