Laserfiche WebLink
Pqu I,N <br /> 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.oro/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST iNSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 0--,h(),r) - �5 '� �� <br /> Facility Address: Service Request#: <br /> C, 0 mcu n rfi I� eco s <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: e)s-1--1 S- <br /> i Lvov- -� <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial #: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El El El❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: ElPrimary s piping testing at: <br /> ❑fail safe Serial #: minutes <br /> ❑ NA <br /> sensorry S on o tainment to ing f r: vpv <br /> El El positive shutdown Model: UDC(s) ��Piping <br /> ❑ fail safe Serial#: Ct Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2°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 <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> c—, <br /> a Q pec <br /> vae Vv t Qtk caks ate. <br /> ,S s\-k-�s . <br /> rsv v W -t-Q vs Q " . <br /> OL f- -t� 'Bruv )(ar r i r �o `u <br /> THIS FACILITY IS SU J CT TO REINSP CTION AT ANY TIME AT EHD'S CURRENT H HRLY RATE. <br /> EHD Inspector: Receiv By- Title: p <br /> EHD 23-04 O UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />