Laserfiche WebLink
Op�1.!?!.N.• C <br />SAN JOAQUIN COUNTY <br />�2 Y ya ENVIRONMENTAL HEALTH DEPARTMENT <br />N >` 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /q ehd <br />q�/FORS` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />a L I.Lc- Z <br /><6 - <br />.6,' <br />Facility Address: <br />Service Request #: <br />I,, -6,q ter- v - <br />c t 4 <br />Onsite Service Technician's Name: <br />IC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <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 />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />FF -7iher: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />(:� L Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <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 />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 21 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 />Corrosion protection <br />FF -7iher: <br />see below <br />❑ This UST facility is APPROVED to operate' This UST facility is NOT APPROVED to op, <br />Le <br />kb -2 <br />Y:I I/ /w'b..� .s I _/ _ J L / �� i/I /� Li- w w. r _.Q �/ G,'Y irk ICi• C L�MU'G%'Iii <br />I THS FACIYTY IS SUBJECT TO REINSPECTION AT MY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins ctor:,, I Received By;//// %% I Title: <br />rA <br />EHD 23-04 � UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />