COMPLIANCE INFO_2009-2012 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sisov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT F Name• Innssjpection Date: •Iq•Oq Facility Address: service Request #: W as slo�C� to Technician'sPaw ICC ce Technicisnflustaller Certifies on A , nufactarer Training: ❑ I �� - g SERVICE s/GW, i N 15 &'•iii[ MR, IK-12 M �lrw Leak detector ❑ ❑ mechanical Model: IRM ► ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model. ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model. ❑ ❑ electronic Serial #: ❑ line test programmed 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) rn�><i1�Ti' 91 SERVICE s/GW, i N 15 &'•iii[ MR, IK-12 M �lrw Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS IRM ► ❑ Caldwell System ❑ Other 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 ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) ❑ Cold start of monitoring panel ❑ Corrosion protection Other- see below FIRE %L10 iIWE=& s/GW, i N 15 &'•iii[ MR, IK-12 M �lrw _ IRM ► EMO- minalyrulval �JiI/�//I►,1.Al.�I /'�� �/� • EHD 23-04 Rev 06122/07 MA