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UV it ,co SAN JOAQUIN COUNTY mac; i< ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 •' `P.• Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd ®R"' - - -10FUNINU1111 K - . .0 SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed a ��9. ]&W! if, Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial : ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ sensor ❑ positive shutdown Model: ❑ fail safe Serial #: 12 fir -h" ❑ 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 LG letter 150-1) SERVICE L Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS a ��9. ]&W! if, ❑ Caldwell System ❑ Other C I r 'ii ■ :� 11 ' 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 ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: LIDC(s) Piping Sump(s) LIST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 20 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 EHD 23-04 Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT L j � a ��9. ]&W! if, C I r 'ii ■ :� 11 ' THIS FACILITY IS SUBJECT TO REINSPECTION ATANY TIME AT EHD'S CURRENT HOURLY RATE. x r . y EHD 23-04 Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT