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oPau.l•c ' P SAN JOAQUIN COUNTY N 2� ENVIRONMENTAL HEALTH DEPARTMENT �. 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd a�/FOK� 1k F Facility Name: Inspection Daten. Facilit re : ( ( & r Service Request#: Onsitp4ilervic Technicia 's Na CC Service T chnician/Installer Exp. Date: Manufacturer mini g: 110 SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: TO REINSPECTION AT ANY TIME AT EHD'SHOURLY ❑ line test programmed ❑ Leak detector El ❑ mechanical Model: ❑ electronic Serial #: ❑ r ❑ 1 a test programmed sensor positive shutdown Model: rail 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) his UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other TO REINSPECTION AT ANY TIME AT EHD'SHOURLY 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 EHD 23-04 Rev 10/06/10 t UST SERVICE REQUEST INSPECTION REPORT TO REINSPECTION AT ANY TIME AT EHD'SHOURLY ReceFA,a EHD 23-04 Rev 10/06/10 t UST SERVICE REQUEST INSPECTION REPORT