Laserfiche WebLink
o.P.�tN• e <br /> a•�''.o� N / SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> OKS <br /> Facility Name: Inspec ion ate: q 7 <br /> l.N d S` — W _..7 <br /> Facility Address: Service Request ii: <br /> Onsite ServiceTechnician's Name: ICC Servic T chnitaanllnstaller xp.Date: Man actu r Training: <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ❑ electronic Serial#: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System 11 Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El —psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <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 /> ❑ fall safe Serial#: Note: Please be are that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every%months menudter. <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 /> r1 ZO <br /> ❑ This UST facility is APPROVED to operate X iitisUST fseiiity-is NOT APPROVED to operate <br /> l <br /> 1 <br /> S t t: <br /> { f <br /> THIS FACILITY IS SUBJECT TO REINS EC ION JkT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I or. Re ived Bv 13 <br /> y: dle: <br /> EHD23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />