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Pq,u rry �o .coG SAN JOAQUIN COUNTY . -��r ENVIRONMENTAL HEALTH DEPARTMENT .y y X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <A- Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sagov.org/ehd •9GiFORt, SERVICE Leak detector �- F1 mechanical Model: v Mr MILM ❑ electronic Serial #:: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: R�eiv6elBy: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor E] ❑ 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 F1 1 hour hydrostatic ❑ Incon TS -STS Mr MILM ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS FACILITYA- THIS • REINSPECTION AT ANY TIME AT EHII CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other R�eiv6elBy: 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. ❑ 1 Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 Q UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12 100" ', i i r; #; i r ► �, i gill Mr MILM G! �' • t • l •J r WWWAIM FACILITYA- THIS • REINSPECTION AT ANY TIME AT EHII CURRENT HOURLY RATE. EHID Inspector, R�eiv6elBy: EHD 23-04 Q UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12