Laserfiche WebLink
raPqutN SAN JOAQUIN COUNTY <br />f//�.• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />iW <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www._sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name://�� �iy <br />69, 5tco /t0 e� <br />' <br />e, IW 3/ <br />Inspection Date: <br />3 3 �b <br />Facility Address: <br />,Z44-0 06171"e-15 <br />A44 <br />Service Reques <br />S k 00743/4 <br />Onsite Service Technician's Name: <br />Jo -se -ph Qr o ld i <br />IGC Service Tech nicianllnstaller Exp. Date: <br />Manufacturer Training: <br />�ve( 712311,6 <br />Pi c i.n +F 1 <br />Siev <br />❑ <br />Leak detector <br />L <br />�y <br />Y �r <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <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 />❑ <br />❑ faii safe Serial #: <br />❑ <br />11 NA <br />X <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 />g This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <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 2' containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />X <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />r - 0 -r Y d - <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspecto�r/: L <br />. I <br />Receive T —� � <br />I -e <br />Ll�e - <br />Title: "' <br />El 23-04 <br />Rev 4130112 <br />UST SERVICE REQUEST INSPECTION REPORT <br />