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SAN JOAOUIN COUNTY <br />*ENVIRONMENTAL HEALTH DEPARTMENT <br />;Z <br />X <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si oy v.or ehd <br />'9�iFpRta <br />Facili Name: <br />Inspection Date: PP <br />n t` <br />Facility Address: <br />4?YO Wo &Ales <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC Service Technician/Insta er Exp. Date: <br />Manufacturer Training: <br />ir♦ , <br />❑ line test programmed <br />❑ <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />1 r <br />❑ electronic Serial #: <br />ir♦ , <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LIS letter 150-1) <br />�X,Thls UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />1 r <br />❑ Caldwell System ❑ Other <br />ir♦ , <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />W <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Te s ing for the above comp nents are next due by' <br />— <br />Note: Please be aware that 2° 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 />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />I+' tFil it►..1 I +y �i a N a <br />1 r <br />ti 0 WE BMWi o'; t r <br />ir♦ , <br />r � i <br />i <br />TWIS FACILITY IS SUBJECT TO REINSPECTIONHOURLY <br />W <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />