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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.or /q ehd SERVICE This UST facility is APPROVED to operate SERVICE —17 Leak detector Spill bucket ❑ minimum 5 gallon mechanical Model "S ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ electronic Serial #: ❑ Caldwell System ❑ Other ❑ line test programmed Spill bucket ❑ minimum 5 gallon Leak detector ❑ ❑ mechanical Model: ❑ Caldwell System ❑ Other ❑ electronic Serial #: Primary piping testing at: ❑ line test programmed psi sensor ❑ ❑ positive shutdown Model: Secondary containment testing for: ❑ fail safe Serial #: UDC(s) Piping ❑ NA Sump(s) UST(s) sensor ❑ ❑ positive shutdown Model Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ fail safe Serial #: Cold start of monitoring panel ❑ NA Corrosion protection 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 pill Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other r Inspector�-q'j 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) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 21 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 If 11=1 pill s � r • r Inspector�-q'j TltI- EHD 23-04 Rev 4130/12 UST SERVICE REQUEST INSPECTION REPORT