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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web. www.sigov.orolehd <br />JNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />SERVICE <br />Thl . s UST facility Is APPROVE[) to operal <br />Wit <br />SERVICE <br />Leak detector <br />— Spill bucket 0 minimum 5 gallon <br />11 <br />0 mechanical <br />Model: <br />0 Caldwell System 0 Other <br />0 electronic <br />Serial #: <br />11 <br />13 line test progr ammed <br />Leak detector <br />Primary piping testing at <br />0 mechanical <br />Model: <br />0 electronic <br />Serial #. <br />Secondary containment testing for <br />D line test ed <br />tEem.qramm <br />UDC(s) Piping <br />« ii Sensor <br />Sump(s) LIST(S) <br />E3 <br />utj <br />positive shu down <br />Model: L-jo <br />Note Please be aware Me reordskyrot oomponards we requM to b&t9ged LVW <br />kwhdabm 6 mcnft after and every 36 mm to awradw <br />11 fail safe <br />Serial t llmqcnk."34310 <br />❑ <br />0 NA <br />❑ <br />Other see below <br />sensor <br />-Positive <br />shutdown <br />model: <br />0 fail safe <br />Serial <br />0 NA <br />sensor <br />0 positive shutdown <br />Model: <br />0fail safe <br />Serial #: <br />11 NA <br />Drop tube with mechanical overfill at 95% <br />Drop tube with <br />mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1) <br />Thl . s UST facility Is APPROVE[) to operal <br />Wit <br />SERVICE <br />— Spill bucket 0 minimum 5 gallon <br />11 <br />0 1 hour hydrostatic 0 (noon TS -STS <br />0 Caldwell System 0 Other <br />Spill bucket 0 minimum, 5 gallon <br />11 <br />®1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at <br />0 <br />psi <br />minutes <br />Secondary containment testing for <br />UDC(s) Piping <br />Sump(s) LIST(S) <br />E3 <br />Testing for the above components are next due by: <br />Note Please be aware Me reordskyrot oomponards we requM to b&t9ged LVW <br />kwhdabm 6 mcnft after and every 36 mm to awradw <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other see below <br />0 This UST facility Is N�OT APPROVED to operate <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT AIN)F <br />Ins or <br />uxh <br />_1 I - <br />r <br />END 23-04 <br />Rev 4/30/12 <br />ra d <br />91AIM <br />UST SERVICE REQUEST INSPECTIORAEPORT <br />