Laserfiche WebLink
pqu I,N <br /> �o. �.co SAN JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> y 1868 Last Hazelton Avenue, Stockton, CA 95205-6232 <br /> Cq�i F p'(iN�P <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 /> a ` ( �Ig� LA-(b-1S <br /> Facility Address: Service Request#: <br /> cl8 3 Sp, 00-9- �3 6 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 2s��� A drof Zolb <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 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 /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El ElElfail safe Serial #: psi <br /> El NA minutes <br /> sensor S-e ondary containment testing for: <br /> ❑ ❑ positive shutdown Model: } UDC(s) `<< P W Piping <br /> ❑ fail safe Serial #: -O +- Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: (o No n-}-h a�� �S- o L4-1.)-4 b) <br /> El fail safe Serial #: Note: Please be aware that tat contT—ainmen�mponents 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 /> On ik� kkAdrn,1a%c, -t vA $ -O o-a-h e ST T <br /> Q.C'Aln& -� 0 n q I -o re t'-vie- ; h0 bC 3 - <br /> VXW A- �Oud' <br /> o �`led r v n et %AAa <br /> 8q- R STS st-imp cwJ clI ockaAn e- ' vi0 <br /> Qd . IQ 6 rmto -f <br /> THIS FACILITY IS SUBJ CT TO REINSPECTION AT ANY TIME AT EHD'S CUR ENT HOURLY RATE. <br /> EHD Inspecto • Rece' By: Title: <br /> 77 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />