Laserfiche WebLink
SAN JOAQUIN COUNTY + <br /> m ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.oro/ehd <br /> 4�tFORN� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:. Inspection Date: <br /> as - 1 <br /> Facility Addr ss: service Re uest#: <br /> Df 0 �3 <br /> Onsite ServiceTechnician's Name: ICC Service Technicianillnstaller Exp. te: Manufacturer Training: <br /> 1 VWM3 aI <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El <br /> F1 electronic Serial#: [ICI1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System EI Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model: El ❑ 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: Primary piping testing at: <br /> �� ❑ psi <br /> ❑ fail safe Serial#: 1 t 2 1 <br /> ❑ NA — _minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fad safe Serial#: Nota. Please be aware that 2°containment components are required to be tested upon <br /> ElNA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> i <br /> �. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins or R ceived By: / Title: <br /> L • <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />