Laserfiche WebLink
SAN JOAOUIN COUNTY <br /> rENVIRONMENTAL HEALTH DEPARTMENT <br /> e �" <br /> u): <br /> 1868 East Hazeiton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.orgiehd <br /> '.C•.• -- - gip,; <br /> ��iFpRN, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service equest it: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> -b--.90 f�D V-(-41-20 ra v <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 /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El El❑ electronic Serial #: 1 hour hydrostatic ElIncon TS-STS <br /> [I line test programmed <br /> ❑ Caldwell System El Other <br /> sensor Primary piping testing at: Cl( f &SIL I 91�1r— <br /> ❑ ❑ positive shutdown Model: C-70 psi b <br /> E! fail safe Serial #: �D V minutes 0—A- `� 1 5 L m-� <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 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 95% ❑ Cold start of monitoring pane! <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 /> % o�� c4vvo cc� V <br /> eA\ <br /> f 0 kwyM W cL* JU2 �( <br /> THIS ArilLIT Is SUBJECTWO REINSPECT N AT,"Y TI E AT EHD'S CURRENT HOURLY RATIJ. <br /> EHD Inspecto R i Title:For\,hen <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />