Laserfiche WebLink
oA0.u'N <br />?�—�'�''•�� SAN aJOAQUIN COUNTY <br />z �_k ENVIRONMENTAL HEALTH DEPARTMENT <br />N.{ :+4 { 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigoy.orq/ehd <br />Cq�l FOR��P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />0c �fb <br />1,^ i <br />Inspection Date: <br />Facility Address: <br />-7,1--� <br />I <br />�1 L..�. ��► CA q5 -40 <br />Service Request #: <br />S(ZXU650) <br />Onsite�S}ervicg,Technician's <br />Name: <br />ICCtSe ice Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Title: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />*L W&C l im ,k , <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Title: <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 />❑ <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 />AThis UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket minimum 5 gallon <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ther <br />*L W&C l im ,k , <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />EHD Inspe <br />❑ Caldwell System ❑ Other <br />Title: <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 20 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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />ON, wil' (A 4vf <br />b(_4zk - <br />�_VKVNIK W I IS -)p ;1 <br />*L W&C l im ,k , <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe <br />RedBy: <br />Title: <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />