Laserfiche WebLink
oR+qu'•,y c i <br /> SAN JOAQUIN COUNTY <br /> pr- <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .. <br /> V. 600 East Main Street, Stockton, CA 95202-3029 <br /> ' Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> �d��FOiR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:, Ins ction Date: <br /> �V <br /> Facility Address: Service Request#: <br /> q3 aq- (1061 PA'-- I SIR co -3, +Lf <br /> Onsite ServiceTechnician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Train' <br /> VMS Tfs�y <br /> t>�� ca`� `V12 C'�,L7-7. <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 g n <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-9n <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket Elmirxihfium 5 gallon <br /> El El mechanical Model: El El1 hour hydrostatic ❑ 1Kcon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System L7 Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrost*(c ❑ Incon TS-STS <br /> ❑ electronic Serial#: f <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other� " • <br /> sensor Q <br /> Primary pi ng testing at: <br /> ❑ positive shutdown Model: '��- Zd0 ❑ I 1 <br /> ❑fail safe Serial #: � <br /> ❑ NA ----,/"minutes /�. <br /> sensorcondary contairjment testing for: <br /> El El positive shutdown Model: UOC(s) Piping <br /> ❑ fail safe Serial#: Su'imip(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 % Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfi at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 15 -1) ❑ Other: see below <br /> VP _ <br /> I!' _Y (171 i� Q t J ui Ct i i'S� r (k <br /> j' --h" li t)') (411110 tk <br /> c144a =F _u� �l O 1 PIV D <br /> 1'1�ttic ivLIL � ir4XA � Z `( t/I (11 <br /> THIS F ILITY IS SUBJECT TO REINSPECTION AY ANY fIME AT END'S CURRENT HOURLY FrATE. <br /> EHD Ins p ctor ned By: Title: <br /> ft- <br /> /003411- <br /> -- I J, K W Ij a <br /> 7 71-o T; a�1 - t Tlo /8 221-6q <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />