Laserfiche WebLink
°(,4utri. 0 SAN JOAQUIN COUNTY <br /> ear i ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd <br /> 9<iFp'a� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPE5TION REPORT <br /> w <br /> Facility Name: In o a <br /> (WVMN <br /> Facility Address: Service Request#: <br /> 4JW3 MA"I 9 C1 S'►aC"n! Sie-d 0 S7 73 z <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> Jess(6 W�rINS 5307S96- UT s/l�/►I g3f (,//0/// <br /> SERVICE SERVICE <br /> PLWLeak detector fM g-c7 Z/ 810C Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial #: 14 QM2 - <br /> line test ro rammed "`— ❑ 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 /> _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 /> ❑fall 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: Phase be aware that r containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every M months thereafter. <br /> ❑ _Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95°/p ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) 1 ❑ I Other: see below <br /> e Pu.b It ,- /o <br /> ✓ 6 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: YY / Re ive Qy;W Title: <br /> EHD 23-04 '/ L UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />