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�o•.PQu � N••,co SAN JOAQUIN COUNTY 4b ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 • `� Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /c /ehd SERVICE i I ilr.i �, y Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: Iwo ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ 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 LG letter 150-1) ❑ This UST facility is APPROVED to operate SERVICE i I ilr.i �, y Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Iwo Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s)r iping Sump(s)UST(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 ,41 This UST facility is NOT APPROVED to operate EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10 i I ilr.i �, y r y� rI Iwo MW1 t y_ il'z / ��'� ■tet ZA I -FHI9 FACII-IfY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10