Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax.(209)468-3433 Web:www.sjgov.or�/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> C4eA,j <br /> Facility Addre Service Request#: <br /> 5F-- oTj3q T <br /> - <br /> Onsite Service Technician's N me: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> vwt; �hL�C_ o <br /> SERVICE SERVICE <br /> Leak detector a <br /> mechanical Model: Wm0I I M Spill bucket ❑ minimum 5 gallon <br /> [� ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: o7Ol{ ❑ 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 /> 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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> ❑ NA minutes <br /> sensor <br /> El positive shutdown Model: Secondary piping testing at: <br /> El El fail safe Serial #: El <br /> psi <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <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 /> � � dv ILU USAAA 4) - IDA RU-D AW ik, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins'!A5ye R e ed By: Title: <br /> ,,��``����JJ1\�` ' ) l C <br /> r7 <br /> EHD 23-04 / <br /> Rev 06/22/07 <br />