Laserfiche WebLink
O Pa U I N'•.0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Insect'on Date: <br /> .� <br /> Facilitell-y Addre,,-/ss: Service Request#: <br /> a t�.1P-n(,ot <br /> Mewice Technician's Name ICC Service Technician/Installer x�D Y: Manufacturer Training: <br /> 141 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ❑ F11 hour hydrostatic F1Incon TS-STS <br /> 11 line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El111 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> W_ ^ sensor ::�: <br /> '�' Primary piping testing at: <br /> P4)positive shutdown Model: ❑ psi <br /> Tlail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail 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 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 /> F-1Droptube with mechanical overfill at 95% ❑ Corrosion protection <br /> El Overfill prevention (see LIS letter 150-1) Other: see below ' �,j <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> t6 <br /> JOVIL �;' ir{hr+c tc� d�Y- ilii' _), <br /> -or-t. U& --N (11�� fi-A" . 'Ten-'k �A_ze� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: RScery y: Zitle <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />