Laserfiche WebLink
• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si¢ov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 4-q /eT3/,u ,/ r o �� 63 <br /> Onsite Service Technician's Name: ICC Service Technician/Instailer Certification#: Manufacturer Training: <br /> jallq f l._ , lir 'S A 3Z 'RA <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: ❑ ❑ 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: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor _ Primary piping testing at: <br /> ❑ ❑ positive shutdown Model' El _psi <br /> El fail safe Serial#: minutes <br /> ❑ NA <br /> 0 1 �i ' '' sensor Secondary piping testing at: <br /> �. D yositive shutdown Model: 1 ] ❑ psi <br /> Q fail safe S aj, #: minutes <br /> El NA <br /> Y-) d sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: 71 .%x- >� S ❑ UDC(s) Piping ' <br /> 0 fail safe +1 2! 15-4 51 Sump(s) UST(s) <br /> ❑ NA < - . I 2 ,. l <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 /> I <br /> If St I vv)p )I 4 1 J y <br /> I i <br /> THIS FACILITY IS SUBJECT TO REINSPE TION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. Received By: Title: <br /> CLJr1 <br /> 11 nA <br />