Laserfiche WebLink
oPQ.0 IN••.c <br /> SAN JOAQUIN COUNTY <br /> N: , •� cNVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> _ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd <br /> c4�iFORr'�`T <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: Itc Service Technician/Installer Exp.Date: Manufacturer Trraaining: <br /> Ll <br /> SERVICE SERVICE <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 <br /> 1:1 mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> tensor <br /> [Ipositive shutdown Model: \j Primary piping testing at: <br /> El psi <br /> El fail safe Serial #: <br /> 'eL�'^'"`"' ,`-''^s"� minutes <br /> 1NA <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 /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> rEJ Overfill prevention (see LIS letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> 1-) �s <br /> THIS FACILITY IP SUB CT TO REINSPECTION AT ANY TIME AT D'S CURRENT HOURLY RATE. <br /> EHD Inspectj/ <br /> Removed B • Title: <br /> '4�hjV� <br /> 09f <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />