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Pq•U 1 ry �o.• ' ,co 0 SAN JOAQUIN COUNTY N: ?< ENVIRONMENTAL HEALTH DEPARTMENT _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �` ;P•. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd Facility Name: Inspection Date: La 7!> -2 2 5 4,2 0 Facility Address: Service Request #: `zL4,tf) Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: - ►�, i / SERVICE SERVICE ❑ This UST facility is APPROVED to operate Leak detector ❑ ❑ mechanical Model: Wt it+ ❑ electronic Serial #: MWAM!_' �1�_ J JI J( 1 %" 1 rat ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: AmeW—MMKOTAIIME ❑ electronic Serial #: line t st programmed ? odel: ❑ positive shutdown Model:.! ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ positive shutdown Model: zo ❑ 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 1 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS Wt it+ ❑ Caldwell System ❑ Other MWAM!_' �1�_ J JI J( 1 %" 1 rat Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other AmeW—MMKOTAIIME Primary piping testing at: PSI minutes Secondary containment testing for: LIDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection E-32" Other: see belowj� L 1pu� v 2u 1 •'` / '� . Jr L �' iiia r 1' l Wt it+ 'iJ .. ..r•� MWAM!_' �1�_ J JI J( 1 %" 1 rat _RR I �� : 1� %� -, �Ji'i�lll,��il � � 1 �,I� �_��It7��li�r►i Rlit►��%1)�./7�� AmeW—MMKOTAIIME ,_Ez.-_ - EHD 23-04 �7 t Rev 4/30/12 - UST SERVICE REQUEST INSPECTION REPORT