Laserfiche WebLink
U.I Af <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �II 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <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: Inspection Date: <br /> ARC 0 A M 12M $ 3333 // Z 30 /5- <br /> Facility Address: Service Request#. <br /> 590 W. Hallo; co Road ,1 rQ6y, CSA SR 007 3740 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> N i k a Za o r o v 5 z1 J 17 Phil —4;+C V707 <br /> SERVICE SERVICE <br /> Leak detector _Spill buckets LY"minimum 5 gallon <br /> ❑ <br /> El mechanical Model: S'1 hour hydrostatic El Incon TS-STS <br /> 11 electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: El Caldwell System El Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> ❑ ❑ fail safe Serial#: El <br /> ❑ NA minutes <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 20 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 /> ❑ 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 11 S;+&— +0 witne S +� I -F I 'f) qi Q,,d <br /> ISp.1 s . -T",e.� I . <br /> 9! 1 <br /> + <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins p or: Received By: Title: <br /> Se r vI i � -Tee <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />