Laserfiche WebLink
oPa�IN c 0 <br /> �e SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> '9GIFpRt, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili y Name: Inspection Date: <br /> ru <br /> Facility Adss: Service Request#: <br /> rao) C4 <br /> n �� <br /> Service Technician's Name I Servi Technician/Install Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket Elminimum 5 gallon <br /> ❑ 11mechanical Model: El El1 hour hydrostatic ❑ Incon TS-STS <br /> Elelectronic Serial #: ElCaldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial #: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: ❑ _ psi <br /> dob <br /> ❑ fail safe Serial #: minutes <br /> ElNA <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 20 containment components are required to be tested upon <br /> ❑ NA I installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% El I 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 ChKti ` V <br /> AThis UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> w <br /> f s ��cA- <br /> THI FACILITY IS SUBJECT TO REINEZPFCTIOA AT ANY AME AT EHD'S CURRENT HOURLY R TE. <br /> EHD Ins <br /> pecto. Rec ived Ti <br /> 6�VA � — - <br /> r/ '/�/ <br /> E H D 23-04 Q� "�/1 V�"/(/� �b7k v r ������/ S rQ/�_ .-j USj SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 r /) ) V/I /%//,(.f►Y�( <br />