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0 SAN JOAQ UIN COUNTY 6 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siQov.org!ehd 18113 01 Do 411M Ila X411a fill W! Ii III I ON as Facility2 P{ame. C! ® Leak detector rj Inspection Date: Facility Address: 16/1 _. tA 01 ❑ line test 2roEammed Service Request N Onsite Service Techian's N#me:ICC ❑ ❑ mechanical Model: service Technician/installer Certification N:Manufacturer Training: SERVICE ® Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: tA 01 ❑ line test 2roEammed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test 2roEammed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test 2roEammed sensor ❑ ❑ positive shutdown Model: --- THIS FACILITY IS SUBJECT TO NSPECTION*T ANY TIME ❑ fail safe Serial #: EHD ins �gr:Received� ❑ 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) SERVICE ® 777 e Spill bucket ❑ minimum 5 gallon 1 hour hydrostatic 9 Incon TS -STS ❑ Caldwell System ❑ Other tA 01 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS r % ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other W i i rr'C Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi --- THIS FACILITY IS SUBJECT TO NSPECTION*T ANY TIME minutes EHD ins �gr:Received� Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below EHD 23-04 tA 01 0.5 t y t J(R 1 ' i h ; Q y firth r % Y7y1 W i i rr'C ex r C�� `. --- THIS FACILITY IS SUBJECT TO NSPECTION*T ANY TIME AT END'S CURRENT HOURLY RATE. EHD ins �gr:Received� By: { I� Title: EHD 23-04