Laserfiche WebLink
�A.�,,,�E '•°� 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 /> 'i65 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Flity me: r Inspection Date: <br /> Fasilitv A dress: Service Request#: <br /> 11 A <br /> �6sck 4 liC <br /> Onsite Service Technici 's Name: ICC Service Technicia nstaller Exp.Date: Man facturer Training: <br /> j �_ IA <br /> SERVICE SERVICE <br /> eak 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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: El Caldwell System El Other <br /> ❑ line test programmed <br /> sensor ,, <br /> El shutdown Model: � �' 6a Primary piping testing at: <br /> ❑ <br /> ❑ fail safe Serial#: f psi <br /> ❑ NA minutes <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 21 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 <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> /10 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> - _U 'ffA_— <br /> VOOL <br /> r. <br /> t <br /> 1N" <br /> Yrs <br /> THIS FACILITY IS S ECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received Title: <br /> ___) k <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />