Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ;,. 600 East Main Street, Stockton, CA 95202-3029 <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 /> Fait,,Nt1me: A qG-`f c t-1r COC-04-2-')4-2- I Nri(nspection a <br /> F 1 .11 ZDf O <br /> Facility Address:�� ��� Sery ce Request#: <br /> �'' �� 0 ash o <br /> Onsite Service Technician's Name: ICC Service TechniclarOnstaller Exp.Date: Manufaotu T Inln : <br /> �► �I v. qr, "u IY°L ST Ir M 5,?soW-iJ1 5r O, o � `� 3AA61t <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> 11 mechanical Model: <br /> El ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: <br /> ❑line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑mechanical Model: <br /> ❑ ❑ El flour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: <br /> ❑ fine test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑positive shutdown Model: <br /> El lett safe Serial#: p El NA �minutes <br /> sensor Secondary containment testin for: <br /> ❑ <br /> El positive shutdown Model: UDC(s) 5 m; Piping <br /> ❑fail safe Serial#: Sump($) �UST(s) <br /> ❑NA <br /> sensor Testing or the above components are next due by: <br /> ❑ ❑positive shutdown Model: - <br /> 0 fail safe Serial#: Note: vt aware that 2"containment wrnponents are required to t>e tested upon <br /> ❑ NA instatiati the 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 /> x'fJ <br /> I- � • • ' <br /> n "ffd9'A <br /> c yv 1; th was Armlljlff <br /> S -t l? <br /> AelidL �Q C'f- i�pt2 r <br /> THIS FACILITT IS CT TO REINSPECTION T ANY IME AT EHI)t CURRENT HCVORLY RATE. <br /> EwD Ins s a %„ Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rt"v I11171M <br />