Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> c 'Za ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: a <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siQov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> (57)Z 1.LG-::t# 5--18'--io <br /> Facility Address: Service Request#: <br /> 14�e-00(.6 �C>C)579,5 6, if <br /> Onsite Service Technician'sName: ICC Service Technician/Ins!!WExp.Date: <br /> w � Manufactuear <br /> x,, � a.m.Ting <br /> �, 1-Ab . l;/J� o :x <br /> — <br /> la ,� <br /> SERVICE SERVICE K- 114119- <br /> Leak <br /> lyLeak detector Spill bucket minimum 5 gallon <br /> ❑ ❑ mechanical Model: ,&l hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: Caldwell System ❑ Other <br /> ❑ line test programmed 3 '^ <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 11 ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial#: minutes <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 panel <br /> ❑ Drop tube with mechanical overfill at 95% Corrosion protection — %r3J <br /> ❑ Overfill prevention (see LIS letter 150-1) Other: see below 4 �yj6 <br /> �Qdlcc� rro5v�- ��3J <br /> 1,-Ji <br /> HIS FACILITY IS SUBJECT TO REINSPECTI T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD spy or: Re Title: <br /> EHD 23- 4 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev <br /> I <br />