COMPLIANCE INFO_1999-2008 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd rTXTnVnrnniT1vn c-rnusr_F, TANW ITTRT) PROGRAM SERVICE REQUEST, INSPECTION REPORT SERVICE Ins ction ate: Facility Na a baoaz' �(l i ►3 % ❑ electronic Serial #: 1,— Facility Address: Service Request #:: mechanical Model: El Onsite Service Technician's Name: ICC Service Technician/Installer Certification #: Manufacturer Training: �n4 cc / w ❑ mechanical Model: ❑ ❑ electronic Serial #: SERVICE At YA Leak detector �(l mechanical Model: % ❑ electronic Serial #: 1,— ❑ line test programmed Leak detector mechanical Model: El ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ,In positive shutdown Model: ��if/1//dV� El 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) i lJ SERVICE �j 2 Spill bucket ❑ minimum 5 gallon .,I15�ME 1 hour hydrostatic ❑ Incon TS -STS ElCaldwell 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: t ❑ 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 EHD 23-04 oe., nal"m7 .,I15�ME EHD 23-04 oe., nal"m7