Laserfiche WebLink
AQu t <br /> �.•'���'•.O <br /> SAN JOAQUIN COUNTY <br /> .4 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sagov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> Facility Address: Service Request#: <br /> Oite Service Technician's Name: IC Service Technician/Installer Exp. ate: Manufactur r Training: <br /> 64 r-t <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System El Other <br /> El line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> aNj A,?--Sensor <br /> Elpositive shutdown Model: Primary piping testing at: <br /> El psi <br /> El fail safe Serial #: <br /> El NA minutes <br /> sensor Secondary containment te;j'b'k <br /> ❑ osi ive shutdown Model: -42� UDC(s) �/�- Piping <br /> fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testi g for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note Please Ve aware that 21 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 /> I Gy <br /> hat*- 4iol"14 <br /> Ly- <br /> THIS FACILITY IP SUBJECT'TgREMSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I p ctor �Reeived B Title: <br /> EHD 23-04 V UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />