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ARutN �o.• , '. c,.co SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT l { 600 East Main Street, Stockton, CA 95202-3029 P.. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s1gov.org/ehd A�iiio. .:. . is a ■ •... - �. ,• ..: • �' Facility Name: Inspection Date: t C FacilityL Address: i Service Request #: 0051699 Onsite Service Technician's Name: I ervice Technician/Installer Exp. Date: Manf cturer Training: 1!!2�QG-7q0-7 11TPk64--i2 11 SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor 4Ur1U61,r ❑ positive shutdown Model ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10 lur II,SUBJECTTHIS -- - .. FACILITY IS REINSPECTIONBMW EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10