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�°Rau t N•'•�o <br />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.sipov.orq/ehd <br />X11 0R� <br />i c ■i 1 115. R . . <br />Facility Name: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Addressf <br />na� 6 - <br />Service Request #: <br />1V o <br />1 <br />site service Technician's Name: <br />ICC Service Technicianlinstaller Exp. Date: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />M <br />SERVICE <br />.ra .�. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Fill <br />RE— <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe 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 />❑ This UST facility is APPROVED to operate <br />SERVICE <br />.ra .�. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Fill <br />RE— <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 />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 <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />.ra .�. <br />Fill <br />RE— <br />THIS FACWTY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br />EHD inspector. Al PAI <br />EHD 23-04 <br />Rev 10/06/10 <br />UST SERVICE REQUEST INSPECTION REPORT <br />