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AQU t ry SAN JOAQUIN COUNTY tn` ` ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd r -• •-. ..• -, • �, •. Facility Name:, Inspection Date: Facility Address: 5 C77 IN mechanical Model V WO Service Request 6X800(a electronic Serial #: b17 1 r. �. • . ♦. 1 1 II&IDINI •ll 1111119-110 =44 ❑ line test programmed Onsite Service Techni ian's Name: Leak detector ICCIII1cian/Installer Exp. Date: Manufacturer Training ❑ electronic Serial #: ❑ ❑ line test programmed SERVICE Leak detector ❑ IN mechanical Model V WO %❑ electronic Serial #: b17 1 r. �. • . ♦. 1 1 II&IDINI •ll 1111119-110 =44 ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ 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 1 r. �. • . ♦. 1 1 II&IDINI •ll 1111119-110 =44 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 III 1!giii� !1111111 r- 1 r. �. • . ♦. 1 1 II&IDINI •ll 1111119-110 =44 WAR" EHD 23-04 v UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10