Laserfiche WebLink
t:•fit .oma SAN JOAQUIN COUNTY <br /> c. .a ENVIRONMENTAL HEALTH DEPARTMEN' <br /> 185 'E`ast Hazelton Avenue, Stockton, CA 9520918232 <br /> Telephone: (209)468-3420 Fax. (209)468-3433 Web:www.siaov.orQ/ehd <br /> Cf4G%F ORa`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> --4- ir�, <br /> F ility me: , ` #— 10 I Inspectiopte: <br /> F ill Address: Q .1"'�'/,vim" ` Service Request), LWM <br /> nsite Service Tech clan's Name: ICC Service Tech ni ianllnstaller Ex Date: Manufacturer erj/TTrraining: <br /> j b'L�-�� -i� <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 /> sensor `! pry piping testing at: <br /> ❑ <br /> El positive shutdown Model: 'rlf�" psi <br /> ❑ fall 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 /> ❑ fall safe Serial#: Note: Please be aware that 2°containment components are required to be tested upon <br /> El 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) El Other: see below <br /> i ubrtiel <br /> ❑ This UST facility is APPROVED to operate This^UST4*1 is NOT APPROVED to operate <br /> V � ktihJ <br /> t , <br /> THIS F C LITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re ed y: T' <br /> pr2.wna.w <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />