Laserfiche WebLink
OPQU I ,N, C <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> , ` . 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 46&3433 Web: www . slgov . org/ehd <br /> CA � � FORa`P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspec ion Date : <br /> F cility Address : Service Request #: <br /> Onsite Service Technician 's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training : <br /> /vl� ,*h <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon T&STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial :: El 1 hour hydrostatic ❑ Incon T&STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at : <br /> El El <br /> positive shutdown Model : El psi <br /> Elfail safe Serial # : <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> El ❑ positive shutdown Model : UDC (s) Piping <br /> ❑ fail safe Serial # : Sump (s) UST(s) <br /> ❑ NA <br /> sensor El Testing for the above components are next due by : <br /> ❑ ❑ positive shutdown Model : <br /> ❑ fail safe Serial # : Note: Please be aware that 20 containment components are required to be tested upon <br /> ❑ NA installation, 6 months after, and every 36 months thereafter, <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LIS letter 150- 1 ) Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ti a44 k/mj <br /> (4 iUti1.� e� C sr cZ 0 rel , <br /> sv e � % ,W a s to /r� W d <br /> A4 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD 17,ector. Received By: Title: <br /> C (4S <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />