Laserfiche WebLink
O�aU€N <br />?•'�t''•ao SAN JOAQUIN COUNTY <br />{ ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <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: <br />C� <br />Inspection Date: <br />6" O -N c"o e (� t, (�L_ <br />❑ mechanical Model: <br />Facility Address: <br />❑ electronic Serial #: <br />Servci�c/e Request #: <br />) / (� 1 <br />,A ` Lg i1 Le <br />❑ <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />l4, <br />❑ <br />SERVICE <br />C� <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />ti lQ �,, , �'� <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTIO <br />❑ fail safe Serial #: <br />EHD Inspector: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model.- <br />odel:❑ <br />❑ <br />1:1fail safe Serial #: <br />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />Overfill prevention (see LG letter 150-1)' <br />This UST facility is APPROVED to operate <br />SERVICE <br />C� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />ti lQ �,, , �'� <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />THIS FACILITY IS SUBJECT TO REINSPECTIO <br />UDC(s) Piping <br />EHD Inspector: <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Title: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below moi,) 1, <br />--__j <br />❑ This UST facility is NOT APPROVED to operate <br />■v t <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />C� <br />C) YUZ 1'- <br />z <br />• � O c' � <br />ti lQ �,, , �'� <br />-fit CS `�� c �,., , <br />THIS FACILITY IS SUBJECT TO REINSPECTIO <br />T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />R d B <br />Title: <br />■v t <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />