Laserfiche WebLink
-506M I �l ED /6"27-69 <br />SAN JOAQUIN COUNTY <br />'�IIAa 'oa ENVIRONMENTAL HEALTH DEPARTMENT no EC����� <br />N.1RLR < <br />600 East Main Street, Stockton, CA 95202-3029 <br />I' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or 2 7 2009 <br />c••. w iP <br />A��FOR� <br />UNDERGROUND STORAGE TANK (UST) PROGRAMA SERVICE REQU� T .` FORT <br />Faci lily Name: <br />Inspection Date: <br />—07 <br />Facility ddress: % <br />w <br />Service Request #: <br />Onsite Service Technician's Name:rym <br />ai <br />nt staller Exp. Date: <br />Manufacturer Training: <br />i - <br />—2cgek <br />(-2, -10 <br />❑ <br />SERVICE <br />Leak detector <br />El <br />❑ mechanical Model• <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ mechanical Model- <br />oder❑ <br />Elelectronic Serial # <br />❑ <br />❑ line test proqrammed <br />Leak detector <br />❑ <br />❑ mechanical Model <br />❑ <br />❑ electronic Serial # <br />❑ line test programmed <br />sensor <br />El <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />oder❑ <br />❑ positive shutdown Model- <br />0fail 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 />u <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <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 containment testing for* <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by - <br />Note: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other see below <br />THIS FACILITY <br />fd'.I7 <br />EHD 23-04 <br />�{(JQI.�('-�... G 1bW'1fi��,ij' a�'►1'0se/•/C�o��l^,^ <br />'--'-..1 <br />A <br />:TION AT�AIW TIME HD'S CURR T HOURLY RAT . <br />By:� Title: <br />FB, sib aw: � <br />d�y�Z UST, SE{2VICE U S INSPEN REPORT <br />