Laserfiche WebLink
• SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,P Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service k1equest#: <br /> ?�0 � � Anl vo. " GY <br /> Onsite Service Technician's Name: ICC Service Tech nicia nA nstaller Certification#: Manufacturer Training: <br /> (2, <br /> SERVICE SERVICE <br /> Leak detector <br /> i Spill bucket El minimum 5 gallon <br /> ❑ mechanical Model: <br /> F-1 ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> [I line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El electronic Serial ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El 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 <br /> El El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> ❑ NAsensor <br /> ❑ ❑ positive shutdown Model: Secondary piping testing at: <br /> si <br /> ❑ fail safe Serial#: <br /> �minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <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 /> C A ,oft, <br /> SC /�0/.1�> <br /> f' <br /> ri <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT I=HD'S CURRENT HOURLY RATE. <br /> EHD Ins tor: ;� Received By- <br /> IA <br /> Title: <br /> v ooJ ['����, �r � <br /> EHD 23-04 <br /> 1/3/07 <br />