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d3 0 SAN JOAQUIN COUNTY 41 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgoy.org/eh <br />N�TWItWILIDYL1111S. 1k, W 04 633A Le <br />.JILIKI <br />Ul <br />Facility Name: Inspection Date: <br />--"-%C <br />.2 (:E;,— 11, 0 <br />Facility Address: Service Request #: I -Onsite— Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: <br />R"M <br />Leak detector <br />0 El mechanical Model: <br />El electronic Serial <br />0 line test programmed <br />Leak detector <br />El 0 mechanical Model: <br />0 electronic Serial <br />0 line test programmed <br />. Leak detector <br />El mechanical Model: <br />0 electronic Serial <br />0 line test proEammed <br />sensor <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />El NA <br />sensor <br />0 positive shutdown Model: <br />El fail safe Serial #: <br />0 NA <br />sensor <br />❑ 0 positive shutdown Model: <br />0 fail safe Serial <br />El NA <br />El Drop tube with mechanical overfill at 95% <br />Ell Drop tube with mechanical overfill at 95% <br />El I Overfill prevention (see LG letter 150-1) <br />EHD 23-04 <br />Rev 06/22/07 <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic F1 Incon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />0 <br />El I hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />❑ <br />0 1 hour hydrostatic El Incon TS -STS <br />El Caldwell System 0 Other <br />Primary piping testing at: <br />El <br />psi <br />minutes <br />—I— <br />Secondary piping testing at: <br />El <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />AZ <br />Cold start of monitoring panel <br />0 <br />Corrosion protection <br />11 <br />Other: see below <br />EHD 23-04 <br />Rev 06/22/07 <br />