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tc ! ly coa _ -�F,—• SAN JOAQUIN COUNTY *NVIRONMENTAL rn HEALTH DEPARTMEN 1868 East Hazelton Avenue, Stockton, CA 95205-6232 - ' (t•. _ `Q Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orc1/ehd �, • •All 1111 1 1111 11 1! � lI 1111111 1 Facility Name: Inspection Date: ti� Cf CU m � Iw-+4-5-4150 13 Facility Service Request #: ^^Address: Ivl� VU Onsite Service Technician's Name: 18C Service TechnicianAns alter Exp. Date: Manufacturer Training: ❑ ❑ mechanical Model: 22 -2/ SERVICE WARME We Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed maik • sensor 25 positive shutdown Model: Ll 3$ fail safe Serial #: W44')Ilv ❑ NA v r 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 WARME We 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 El 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 WARME We THIS FACILITY IS SUBJECT TO REINSPECTION , r. AT r CURRENT O - RATE. .-Rece i v edBy El 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12