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OP`4ulN'• C O SAN JOAQUIN COUNTY Q` ENVIRONMENTAL HEALTH DEPARTMENT m x 1868 East Hazelton Avenue, Stockton, CA 95205-6232 `P.Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd q��FpRtj �( This UST facility is APPROVED to operate Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed IIID f i ,/ sensor ❑ ❑ positive shutdown Model: 'A [AW05 ❑ 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 0 This UST facility is NOT APPROVED to operatb Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS y ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi IIID f i ,/ minutes PA Secondary containment testing for: 'A [AW05 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 below4l >1 V 0I. kCe 0 This UST facility is NOT APPROVED to operatb EHD 23-04 v Rev 4/30/12 v UST SERVICE REQUEST INSPECTION REPORT 17 ANAM-FAINUMMINEWES 14444 1, Ill jj�njjiil�j 1 w r �. v 0%� 3 a 11CMAMMA y IIID f i ,/ / f PA ILI 'A [AW05 EHD 23-04 v Rev 4/30/12 v UST SERVICE REQUEST INSPECTION REPORT