COMPLIANCE INFO_2011-2012 - Laserfiche WebLink

Home Browse Search

OAQU I Iy Q SAN JOAQUIN COUNTY 10 Q� ENVIRONMENTAL HEALTH DEPARTMENT N. X 600 East Main Street, Stockton, CA 95202-3029 `P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd Facility Name: Inspection Date: '+ ❑ Facility Address: Service Request #: Onsite Service Technician's Name: I ICC Se ice Technician/Installer Exp.Date: Manufacturer Training: ❑ —I ❑ SERVICE 12 Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Receiv rt sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE 12 Spill bucket inimum 5 gallon ❑ 1 hour hydrostatic ❑ Incon TS -STS Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi Receiv rt minutes Secondary containment testing for: UDC(s) Piping Sump(s) no UST(s) Testing for the above components are next due by: Note: Please be stare that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EH D 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT 12 THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD I e r: Receiv rt Title: EH D 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT