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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s0gov.org/ehd <br />Facility Name: <br />Inspection Date: <br />Q , r4 <br />1' <br />Facility Address: <br />Service Request #: <br />cci I 1tQ <br />V 6 p b <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ Caldwell System ❑ Other <br />Leak detector <br />B <br />SERVICE <br />rffl- This UST facility is APPROVED to operate <br />SERVICE <br />Leak detector <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ mechanical <br />Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic <br />Serial #: <br />❑ <br />❑ line test programmed <br />❑ Caldwell System ❑ Other <br />Leak detector <br />Primary piping testing at: <br />❑ <br />❑ mechanical <br />Model: <br />minutes <br />❑ electronic <br />Serial #: <br />❑ line test programmed <br />Sump(s) UST(s) <br />«� sensor <br />Testing for the above components are next due by: <br />❑ positive shutdown <br />Model: ® 1 <br />Cold start of monitoring panel <br />❑ fail safe <br />Serial #: 1,9a 3,9,0 <br />A <br />sensor <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ fail safe <br />Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown <br />Model: <br />❑ fail safe <br />Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />rffl- This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />M-, <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below rr a <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 v - <br />UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />TOWILAr'r <br />M-, <br />EHD 23-04 v - <br />UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />