Laserfiche WebLink
oq,QUl!". o <br />�••'rFE'••oG SAN JOAQUIN COUNTY <br />�- -� ENVIRONMENTAL HEALTH DEPARTMENT <br />y 600 East Main Street, Stockton, CA 95202-3029 <br />.P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />q�l F ORa` <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />G <br />IT— <br />Inspection Date: <br />Facility Address: <br />U&wbice. blil. <br />, t-ckl (A <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC Se ice Technician/In alter Exp. Date: <br />Manufacturer Training: VJ•41-kj <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />EHD Imsp@gpr: ;1`��� - <br />� V \ <br />SERVICE <br />Y r 'Ka ' <br />Leak detector I , <br />❑ <br />mechanical Model. <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />EHD Imsp@gpr: ;1`��� - <br />� V \ <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 />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />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 />This UST facility is APPROVED to operate <br />SERVICE <br />Y r 'Ka ' <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 />EHD Imsp@gpr: ;1`��� - <br />� V \ <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 2° 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 />❑ <br />Corrosion protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />SR 1111 a u" 1tYS",0tiIT11,r, 1"1.111 �`IS "'►'3• i1� <br />Y r 'Ka ' <br />WK \iA te NA- V(2 c4ej • <br />ii <br />l S' t <br />F <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Imsp@gpr: ;1`��� - <br />� V \ <br />Receiv <br />Title: <br />ee <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 j/// <br />