Laserfiche WebLink
i <br />OpQUtN C - <br />�•'-_' •a� SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.su oq v.org/ehd <br />q � F O•R�` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Note: Please be aware that 21 c <br />Inspection Date: <br />611-7-ApVro, <br />❑ mechanical Model: <br />`-251-2,q I-a— <br />Facility Address: <br />Cold start of monitc <br />Service Re uest #: <br />2 <br />j <br />❑ <br />Onsite Service Technician's Na <br />Corrosion protectio <br />IW Se ice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />r-4 r ! r-/ s <br />Mi R 29, 201 - :X11 PH <br />-7-/7---/-3 <br />V /z —ILS -3x^ <br />SERVICE <br />Note: Please be aware that 21 c <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />Cold start of monitc <br />❑ line test programmed <br />Receiv By: <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Corrosion protectio <br />❑ electronic Serial #: <br />❑ line test programmed <br />Mi R 29, 201 - :X11 PH <br />'D;e,5v- xk!.s ensor nn <br />Wz 04CiAuN--- <br />d❑ <br />positive shutdown Model: <br />❑ fail safe Serial #: �.iT1 A <br />RESULT = OK <br />L�<A <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket <br />❑ ❑ 1 hour hydrostatic <br />❑ Caldwell System <br />Spill bucket <br />❑ ❑ 1 hour hydrostati <br />❑ Caldwell System <br />❑ minimum 5 gallon <br />❑ Incon TS -STS <br />❑ Other <br />m R aallon <br />Primary piping testi <br />❑ psi <br />minutes _r1;i !i r:.:. l; HLHRM <br />!II <br />Secondary containr r,l._; Wil <br />UDI MAR 29. -012 ":40 P11 <br />Sur <br />❑ Testing for the abw <br />❑ This UST facility is <br />Note: Please be aware that 21 c <br />installation, 6 months after, and <br />❑ <br />Cold start of monitc <br />EHD Inspector <br />Receiv By: <br />Title: <br />CUPJF I Rt°1rT I C'+N REPORT <br />❑ <br />Corrosion protectio <br />D 8 :Mai n t e•nan .:e <br />Mi R 29, 201 - :X11 PH <br />Ell <br />Other: see below <br />I10DE = FACS I111 LE <br />RESULT = OK <br />❑ This UST facility is <br />EHD 23-04 � UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector <br />Receiv By: <br />Title: <br />EHD 23-04 � UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />