Laserfiche WebLink
PqU I!y <br /> SAN JOAQUIN COUNTY <br /> 2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: a <br /> y: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> \L i rr p�R N <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: i Inspection Date: <br /> avnon <br /> Facility Address: Service Request #: <br /> Onsite Service Technician's Name: ICC Se e Techr.icianiInstaller Exp. Date: Manufacturer Trainir-,: <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 /> sensor <br /> ❑ Primary <br /> F-1positiveshutdown Model: ElS piping testing at: <br /> ❑fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: _ UDC(s) Piping <br /> ❑ fail safe Serial#: _ Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fail safe Serial #: Note: Please be aware that 2°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 LG letter 150-1) Other: see below . ya/D VI V. <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> m a99 r i v . r <br /> vJ� • \n.0 row.) e� <br /> NS — Q",+ I S+(X& <br /> 6 baa/0) Q-rQ- tMQxo-k � r <br /> LTHIS PACILITY IS SUBJECT'TO REINSPECT!CN AT A Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHDector: ' - e : T �— <br /> EHD 23-04UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 1 aq <br />