Laserfiche WebLink
SAN JOAQUIN COUNTY <br />✓ ENVIRONMENTAL HEALTH DEPARTMENi- <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehil <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />l9SA h�S S��tL7/vJ <br />o Z22 <br />Inspection Da <br />7� v� <br />Facility Address: <br />2 13 2 M,Qr <br />ServicJT80t <br /><< <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Certification #: <br />Manufacturer Training: <br />Val er /Ln) L <br />❑ <br />❑ mechanical Model: <br />Spill bucket ❑ minimum 5 gallon <br />rpm W-5 <br />SERVI E <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Spill bucket ❑ minimum 5 gallon <br />❑ electronic Serial #: <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ line test programmed <br />❑ Caldwell System ❑ Other <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />psi <br />❑ electronic Serial #: <br />minutes <br />❑ line test programmed <br />Secondary piping testing at: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />minutes <br />❑ fail safe Serial #: <br />Secondary containment repairs for: <br />❑ NA <br />UDC(s) Piping <br />sensor <br />y� <br />❑ positive shutdown Model: <br />Cold start of monitoring panel <br />Mail safe Serial #: <br />Corrosion protection <br />❑ NA <br />Other: see below <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />rpm W-5 <br />SERVI E <br />L ZU NU af\ <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />r)e v\,j <br />❑ Caldwell System ❑ Other <br />ori tl <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />EHD 1Qspector <br />❑ Caldwell System ❑ Other <br />Receive y: <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />_ L °I - <br />L ZU NU af\ <br />a , w <br />1 KA -40-\, . NhelC �S <br />l be 4-� <br />r)e v\,j <br />i U e4av <br />ori tl <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD 1Qspector <br />- <br />Receive y: <br />Titled <br />e— <br />M <br />EHD 23-04 <br />1/3/07 <br />