Laserfiche WebLink
SAN 7OAQIL P! COUNTY <br />isNV 1RONMin i i a,t. REAL, F• foENT <br />600 East MainStreet, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.ur i W <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspe tion Date: <br />Facility Address: I <br />IV-) i ' 544 vti, <br />Se vice equest #• <br />�� 0053 <br />Onsite ServiceTechnician's Name: ICC ServicifTechnicianfinstaller Certification #: <br />Manufacturer Training: <br />❑ electronic Serial #: <br />J<— <br />SERVICE <br />_ Leak detector <br />❑ <br />D mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />� S4 w-4 <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />EHD Inspector: <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />_ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />,W <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <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 />SERVICE <br />Spill. bucket ❑ minimum 5 gallon <br />❑ <br />❑ l 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 />� S4 w-4 <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />EHD Inspector: <br />❑ Caldwell System ❑ Other <br />Receiv <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 />,W <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />- v <br />=HD 23-04 <br />Rev 06/2?/07 <br />r <br />vA51'7� <br />� S4 w-4 <br />C�Tt t�'E <br />THIS FACILITY IS SUBJECT TO REIN ECT N AT <br />ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />zg <br />Receiv <br />Title: <br />- v <br />=HD 23-04 <br />Rev 06/2?/07 <br />