Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> N; I 1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ > 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.slgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 1 46 <br /> ^� � I <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: M nufacturer Training: <br /> a YY <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model: Spill bucket <br /> El mechanical 5 gallon <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon T"-S`S <br /> ❑ electronic Serial #: El Caldwell System �Other El line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <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 2°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 9500 ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 950,0 ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> is ST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> �I <br /> t SIPN Vk WA06 W,V_ W/4" ­r'a cuq6a_tu kwiro <br /> aid 5 24 JwA 12;13D1Na <br /> 2, <br /> AI <br /> A1Jk CAh 0v-, -!t�1_30 ' t,J <br /> 3 c vt,S <br /> q1 �� �� <br /> THIS FACILITY IS SUBJECT TO REINSP . I AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD:nspe r. �A ce Title- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />