Laserfiche WebLink
�A�uIN' Q <br />SAN JOAQUIN COUNTY <br />' ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />q�/FO'Ra� <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facilit Na e: M42/Inspection <br />` <br />Date: <br />O --J)i q <br />v <br />❑ <br />Facility <br />d ress: <br />-T�k(ff �AR Mi <br />Service#: <br />04-7 <br />VWAXI <br />IN LMA <br />❑ <br />O ite ervica Tec an'Name: <br />ICC Servicrre'',,Technician/Installer Exp. Date: <br />Manufacturer Training: <br />61�M3 <br />I <br />' �G� <br />❑ <br />, <br />SERVICE <br />MAMA [ t""s I i ., ! 17 rd ff'.1L ,F ■I <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />VWAXI <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <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 />❑ 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 />—r- t - - <br />SERVICE <br />MAMA [ t""s I i ., ! 17 rd ff'.1L ,F ■I <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />VWAXI <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />EHI) In,•or: <br />❑ Caldwell System ❑ Other <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 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel ljo tWe <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />MIN-Wit-Wa-TIVAMMA011 <br />MAMA [ t""s I i ., ! 17 rd ff'.1L ,F ■I <br />OW <br />MAY rfffl�% <br />VWAXI <br />w <br />• • .[PI IVA;Y-Iltg =1111111 <br />EHI) In,•or: <br />EHD 23-04 V V <br />Rev 4/30/12 <br />41 <br />(/ UST SERVICE REQUEST INSPECTION REPORT <br />