Laserfiche WebLink
y. E •off SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (2.09) 468-3420 Fax: (209) 468-3433 Weft:www.sigov.orq/ehd <br /> UNDERGROUND STORAGE TANK (LIST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 'V e,r f'9 4-- 151 1'I — <br /> Facili y Address: Service Request#: <br /> 1—f-el 510 4 .1 ;A )C:)6 1.3 0 <br /> Onsite Service Technician's Name: ICG Service Tecfinicianfin-sta�ller-Exp. Date: Manufacturer Training: <br /> 1'0 1••r. r .plc=c7 ,t?� 'a ! ���--' C% � J <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket minimum 5 gallon <br /> El ❑ electronic Serial: El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed 171 Caldwell System ❑ Other <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 Primary piping testing at: <br /> ❑ positive shutdown Model: ❑ psi <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 21 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 <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> t <br /> GLI< � rte...-- — S V �I b.•,���- .�y 1L?r.ts.� X25'� ��-- ''ll 1-�•-�•5 5;� <br /> THIS FACILITY IS SUBJECI TO REINSPECTION NY TIME AT E'ND'S CURRENT HOURLY RATE. <br /> EHD Inspec Received B Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10106/10 <br />