Laserfiche WebLink
i <br /> I <br /> QAq U P!Y••.0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ` Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.orglehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> . 14 <br /> Facility Address: Service Request#: <br /> C f-.I <br /> Onsite Service Technician's Name: ICQ_Service Technic ian/lnstalleF ler Exp.Date; Manufacturer Training:'Tb <br /> 4"ill I's`KL <br /> N'4}�+G V�tr I Qt-i[!y1 Cl�ayitl+'t'�'cs <br /> SERVICE SERVICE = <br /> Leak detector �- <br /> ❑ mechanical Model: Spill bucket F1 minimum 5 gallon <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: L1 Caldwell System F1 Other <br /> F1 line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> positive shutdown Model:Ll [Ifail safe Serial #: X52 p <br /> El NA minutes <br /> sensor Secondary containment test-ng for: <br /> ❑ ❑ positive shutdown Model: UDC(s) �� Piping = <br /> Q fail safe Serial#: Sump(s) UST(s) E <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive Shutdown Model: <br /> ❑ fail safe Serial #: Note: Please he aware that 2°containment components are required to be tested upon <br /> ❑ NA installation.6 mcnihs 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 /> o,&it QSj <br /> ZiQaul6a a'i ' `TT 'y wee - <br /> oil <br /> A" 4r LAS +0 & +o "t QA '--YDQP -JM-VA M -&I jQ;l <br /> & <br /> > f n - U►1 .4 v1 c 4 <br /> THIS FACILITY IS S BJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec'or: Receiv By: Title <br /> UZ-1ALL <br /> _ <br /> wuc -7 J <br /> EH 23-D4 ` UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 [� � p � <br />