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SAN JOAQUIN COUNTY y: < ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 . ;� • Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd q�/FORa 1 • 11117 i ■ . ` . . . s . . . SERVICE ICE Spill bucket ❑ minimum 5 gallon Leak detector ❑ ❑ mechanical Model: ❑ Caldwell System ❑ Other ❑ electronic Serial #: Spill bucket ❑ minimum 5 gallon ❑ line test programmed ❑ 1 hour hydrostatic ❑ Incon TS -STS Leak detector ❑ ❑ mechanical Model: Primary piping testing at: ❑ electronic Serial #: psi ❑ line test programmed minutes sensor ❑ ❑ positive shutdown Model: UDC(s) Piping ❑ fail safe Serial #: Sump(s) UST(s) ❑ NA Testing for the above components are next due by: sensor ❑ ❑ positive shutdown Model: Cold start of monitoring panel ❑ fail safe Serial #: Corrosion protection ❑ NA Other: see below 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 This UST facility is NOT APPROVED to operate r10Ir 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 I ❑ 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 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 below This UST facility is NOT APPROVED to operate r10Ir ! r �. Vill - t9j.' • .. • , - W1.4 I EHD 2W4 / 1� Rev 4/30/12 `— UST SERVICE REQUEST INSPECTION REPORT