Laserfiche WebLink
y- <br /> e° NW, SAN JOAQUIN COUNTY `iW <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 600 East Main Street, Stockton, CA 95202-3029 <br /> '. <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> �C/FO'RN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili Name: Inspection Date: <br /> Facility Addres Service Request 11: <br /> Onsite Se Technician's Name: ICC Service ec nician/I staller E .Date: Manufacturer Training: <br /> CG � � <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> ensor Primary piping testing at: <br /> positive shutdown ModelC ❑ psi <br /> ❑ fail safe Serial#: tl/, <br /> ❑ NA _minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA Elsensor Testing for the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note Please be aware that 2 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every w mons 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 LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> A 1/11111 <br /> L - <br /> THIS FACILITY IS SUBJECT TO REINS PECTIO AT ANY E AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspecto Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />