Laserfiche WebLink
oP4uly c • <br /> ate,'OZ • SAN JOAQUIN COUNTY <br /> m i ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P 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: Inspe�tion'Date: <br /> (� Gf'v 2 4 <br /> Facility Address: <br /> Serxice Request#: <br /> Ons!%,Aervice Technician's Name: ICC Service Technicianinnstaller Ex .Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ ❑ mechanical Model _Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test pro6rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> ❑fall safe Serial#: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testin f r: <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 /> El ❑ positive shutdown Model: `? 04 d p",J&os�3} <br /> ❑fail safe Serial #: —P 1' <br /> Cl NA Note: Please=aware that2'cowry 6 componentsare requlretl la Oe te§eG upgy <br /> installa6°n,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 /> ❑ Overrill prevention ((see LG letter 150-1) El Other: see below <br /> v Y\ PoTej r; I✓ w�ltle <br /> teeu <br /> JIJIS CILV IS SU JECT TO REINSP CA HD'S CURRENT HOURLY RATE. <br /> EH ns i X <br /> d Ti <br /> i <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />