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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.sigov.org/ehd <br />I SERVICE I <br />SERVICE <br />Leak detector <br />— Spill bucket El minimum 5 gallon <br />❑ <br />El mechanical <br />Model: <br />El Caldwell System El Other <br />0 electronic <br />Serial #: <br />El <br />0 line test programmed <br />Leak detector <br />El <br />El mechanical <br />Model: <br />Received By: <br />El electronic <br />Serial #: <br />Primary piping testing at: <br />0 line test programmed <br />psi <br />Leak detector <br />minutes <br />El <br />0 mechanical <br />Model: <br />UDC(s) Piping <br />0 electronic <br />Serial #: <br />El <br />0 line test programmed <br />5-) 4ArV&%jA#— sensor <br />installation, 6 months after, and every 36 months thereafter. <br />0 positive shutdown <br />Model: <br />El <br />�Wfail safe <br />Serial #: (v <br />Other: see below <br />4CA il <br />jil 'Isbrisbir ' <br />b positive shutdown <br />Model: V P-1 If <br />0 fail safe <br />Serial #: <br />NA <br />sensor <br />F_1 <br />El positive shutdown <br />Model: <br />• fail safe <br />Serial #: <br />• NA <br />El <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />0 <br />Overfill prevention (see Ill letter 150-1) <br />SERVICE <br />— Spill bucket El minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System El Other <br />I Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS; <br />0 Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />Received By: <br />El Caldwell System 0 Other <br />Primary piping testing at: <br />El <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />El <br />Testing for the above components are next due by: <br />Note: Please be aware that 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />El <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />El <br />Other: see below <br />Ell 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />f <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY IMME D'S CURRENT HOURLY RATE. <br />11 EHD Insp <br />--JIMA <br />& <br />Received By: <br />Ell 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />