Laserfiche WebLink
oPaulN' c <br /> ?•''�'`''•�� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ' • `P Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Dae: <br /> Ars <br /> awks 0 14-4f q 2! a <br /> Facility Address: Service Request#: <br /> 20"'!fj W. Lod6• e"f X5210 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufac urer Training: <br /> f�O�tJ�.LL , Svc �4 5-1v-// �'"ri", G►Y� /ii7 hj /)/j/- 0 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector Spill bucket Elminimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> ❑ NA minutes <br /> sensor Sec ndary containment testing for: <br /> ElElpositive shutdown Model: 6 UDC(s) Piping <br /> El fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testi g for the above components are next due by: <br /> El El positive shutdown Model: 3� 2 D <br /> ❑ fail safe Serial#: Note: Please be aware that 21 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ®YIJ' W/�reS d I• 1h s 1i <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD ln;M��S R ved By Titles <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17/(08 <br />