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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.sigov.org/ehd <br />.......... <br />0 <br />L- k�i I I I L =iMil I F fib� 1 1: 1� <br />Facility Name: <br />L <br />Inspection D. <br />FacilitX Address: <br />-4 <br />I )- V W. <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC Service Technicianlinstaller 5R 7 Date: <br />4 4062 IAT <br />Manufacturer Training•: <br />CA" q4W.-iII <br />SERVICE <br />iN,70RA1115 sli- <br />1 M,17,22 <br />0 <br />F" <br />Leak detector <br />F-1 <br />El mechanical Model: <br />EHuD InLsppetor: <br />L <br />0 electronic Serial #: <br />0 line test programmed <br />El <br />Leak detector <br />El <br />0 mechanical Model: <br />0 electronic Serial #: <br />El <br />0 line test programmed <br />Leak detector <br />El <br />0 mechanical Model: <br />El <br />El electronic Serial #: <br />El line test programmed <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />0 NA <br />sensor <br />E] <br />0 positive shutdown Model: <br />❑ <br />1:1 fail safe Serial #: <br />El <br />11 NA <br />El <br />sensor <br />El <br />0 positive shutdown Model: <br />• fail safe Serial #: <br />• NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />0 <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />iN,70RA1115 sli- <br />1 M,17,22 <br />0 <br />F" <br />— Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />EHuD InLsppetor: <br />L <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />El 1 hour hydrostatic 0 Incon TS -STS <br />• Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />• Caldwell System 0 Other <br />Primary piping testing at: <br />El <br />psi <br />minutes <br />Secondary containment testing for: <br />V -Z- l C(s) 411 (15 L t 111 _ Piping <br />U I <br />!§Mp(s) — _. UST(s) <br />Testing for the above components are next due by: <br />-A 1A <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 />El <br />Corrosion protection <br />El <br />Other: see below <br />IMMEW. "ITSERAMmmum wavormcmaw", <br />iN,70RA1115 sli- <br />1 M,17,22 <br />0 <br />F" <br />its <br />W nT E/ MV, ffilm Mij <br />�WWAT ANY Ta.-', AT EHD'SC'URRENT HOURLY RATE. <br />EHuD InLsppetor: <br />L <br />M <br />EHD 23-04 <br />Rev 11/17//08 <br />F <br />UST SERVICE REQUEST INSPECTION REPORT <br />