Laserfiche WebLink
ip <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orglehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> k eve 3,21 -fir <br /> Facility Address: Servicequg est#:q ^( <br /> a sbsl N vJ -Ac tF��^'�C, sy <br /> Onsite Service Technician's Name: ICC Service Technicianllnstal ate: Manufacturer Training: <br /> `1a <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑Other <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ❑ electronic Serial#: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial#: p <br /> ❑ NA —minutes <br /> sensor Secondary containment testing for. <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fail safe Serial#: Note: Please be aware that 2°containment components one required to be tested upon <br /> ❑ NA installation,6 months a/ler,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 /> 0 IgizA hycA-�/o <br /> A ee Mewk )ai <br /> 1 <br /> A ( ` r <br /> THIS FACILITY ISSUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> e,aEHD Inspector: Ivetl B /, N <br /> Q <br /> Title0f&C7 ArJ/9T12 <br /> EHD 23-114 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />