COMPLIANCE INFO_2011-2012 - Laserfiche WebLink

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oPaUIN .c SAN JOAQUIN COUNTY . _ ENVIRONMENTAL HEALTH DEPARTMENT copy y 600 East Main Street, Stockton, CA 95202-3029 c• P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd q<�FoRN` UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: / 6 F'G� l ✓`'7 �'<1 ! {C j C�a t.. Inspection Date: ❑ ❑ mechanical Model: Facility Address: Service Request #: ❑ Leak detector ❑ Onsite Service Technician's Name: r4^) tl1C ICC Service Technicianlinstaller Exp. Date: Manufacturer Training: J� . '4 TorG �. ` a '7' qtr ..� .,. 0// ,.�E --� / /r tr w .4 SERVICE / 6 F'G� l ✓`'7 �'<1 ! {C j C�a t.. Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: r4^) tl1C ❑ electronic Serial #: ❑ ❑ line test programmed 0// sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: .�,�4 ,;K J�'��. c- ❑ fail safe Serial #: THIS FACILITY IS SUBJECT tO REINSPECTION AT A0 ❑ 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 / 6 F'G� l ✓`'7 �'<1 ! {C j C�a t.. Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS it'✓W ❑ Caldwell System ❑ Other r4^) tl1C Primary piping testing at: ❑ psi 0// minutes Secondary containment testing for: 11A;�7< lcy UDC(s) Piping 91 -5-Tp, Sump(s) UST(s) Testing for the above components are next due by: 6 %A Note: PI se be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ j Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 Rev 10106110 UST SERVICE REQUEST INSPECTION REPORT / 6 F'G� l ✓`'7 �'<1 ! {C j C�a t.. 67 y d n / V".( '^ G- `� •`� ' : � . ,, c: f c r• 1 I u...9.++ I T , fP %G� �l, it'✓W �'Y { C 5 S r?-- �Ac r4^) tl1C 1 n,`{'.r,lr�Yt�'u� � •�� /tE.sr..��' 0// _5�!IC: X45 l�'PJIk',(� Y, j�.l �:.i �.i:aP`1:.:.•c�l ,'p:,rip�-'>�'� �./ 1c2c:-�' ✓'i7C�lnc�-"� �_ti',�r. �j1r1'•�-C..�..... t.JC.S �?::lfl-.. �.LI.I� .�,�4 ,;K J�'��. c- 'G�r..�- l�T` I!`�"� THIS FACILITY IS SUBJECT tO REINSPECTION AT A0 TIME AT EHD'S CURRENT HOU LY RATE. EHD In or: , Receiyed-6w=•�---; Title: EHD 23-04 Rev 10106110 UST SERVICE REQUEST INSPECTION REPORT