Laserfiche WebLink
o�q'' t c <br />P SAN JOAQUIN COUNTY <br />Q ENVIRONMENTAL HEALTH DEPARTMENT <br />N 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.s'gov.org/ehd <br />q�IFORN� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />(JlS, CIV04il? iav <br />Inspection Date: <br />4� <br />Leak detector <br />❑ <br />Fact ity Address: <br />1-7V �� 1 2 ` <br />Service Request #: <br />G2�o; <br />Onsite Service Technician's Name: <br />ICC Service Tech nician1Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />Leak detector <br />❑ <br />SERVICE <br />M1 W18MM, <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />• •[fill <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <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 />This UST facility is APPROVED to operate <br />SERVICE <br />M1 W18MM, <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 />Igi <br />.11r ' e` ► G�ih]a� ten. 1 MWIFINSM0111' <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />• •[fill <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 />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 f j UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 v <br />M1 W18MM, <br />Mum <br />Igi <br />.11r ' e` ► G�ih]a� ten. 1 MWIFINSM0111' <br />r <br />i FA <br />• •[fill <br />EHD lnspecto�/ <br />EHD 23-04 f j UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 v <br />