Laserfiche WebLink
AQUIW <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �tA i <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.segov.org/ehd <br /> 4L1FORf� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: il Inspection Date: <br /> C4)QW00 o) 5 '` -a _U� <br /> Facility Address: Service Request#: <br /> �140 � n, <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> C�1ati titin ; V-\ <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic 11 Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El El hour hydrostatic [I Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System ❑ Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> F71 si <br /> ❑ fail safe Serial #: ❑ minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model.- <br /> El <br /> odel:❑ fail safe Serial#: Note Please be aware that 20 containment components are required to be tested upon <br /> ❑ NA 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 S S <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> i v S� -A alb- �t• �rX - ti�-�ea 0 <br /> ry/ i L6 0t -erg 0 L, S <br /> v11 Oo© c-,w v1 Ly 3 V P.d <br /> tai N-0-6 V.A. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIMEAT EHD'S CURRENT HOURLY RATE. <br /> EHD In ectar: Recei B Title: <br /> 6� <br /> EHD 23-04 UST SERVICE REOWEST INSPECTION REPORT <br /> Rev 4/30/12 <br />