COMPLIANCE INFO_2009-2012 - Laserfiche WebLink

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PgUIN �o.• '�.coG SAN JOAQUIN COUNTY ri .r—Tcrr—: Z ENVIRONMENTAL HEALTH DEPARTMENT y? 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjclov.org/ehd q�/FORS UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: -7/ I V ❑ mechanical Model: 1 Facility /IA,�ddress: 2�11/o Service Request #: Q Onsite Service TechniciName: Leak detector ❑ ICC Service Technician/Installer Exp. Date: Manufacturer Training: ❑ electronic Serial #: `�r``// ❑ line test programmed ll l0 n IVP, Q'p SERVICE Leak detector ❑ ❑ mechanical Model: ❑ 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: rCold ❑ ❑ 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) 6 SERVICE 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 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware.that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. start of monitoring panel rCold ❑ Corrosion protection ❑ Other: see below EHD 23-04 Rev 11/17//08 a UST SERVICE REQUEST INSPECTION REPORT %i EHD 23-04 Rev 11/17//08 a UST SERVICE REQUEST INSPECTION REPORT