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A(AU i ty SAN JOAQUIN COUNTY e a NVIRONMENTAL HEALTH DEPARTMENT { PL 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd AilF0 Facility Name: 1_)? Inspection Date: 5 — 0 & —_ 2401 P 0 Facility Address: Service Request #: Onsite Service Technician's me: ICC Service Technician/Installer Exp. Date: Man4 4 ❑ Leak detector ❑ SERVICE Mnftp .:. �j" is Leak detector ❑ ❑ mechanical Model: I ter. rr. 1.1mw ❑ electronic Serial #: is ❑ 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 LIS letter 150-1) This UST facility is APPROVED to operate SERVICE Mnftp .:. �j" is Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS I ter. rr. 1.1mw ❑ Caldwell System ❑ Other is 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 21 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 EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT Mnftp .:. �j" is _ ■ ■i '� ^. Ii .. .moi• �1'�WSlf�i .- �: I ter. rr. 1.1mw [1'�i 11 •. % . Y . is L ` / N , " _ - THIS FACILITY IS SUBJECT TO REINSPE • , CURRENT RATE. EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT