Laserfiche WebLink
f <br /> p4...N <br /> SAN JOAQUIN COUNTY <br /> is yi tl ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> r. Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> @q��.:.....i j <br /> FOR <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> p' Inspection Date: ''^^ <br /> l— - 1 —�W <br /> Facility Address: Service Request#: <br /> 36Ons - 5 Z <br /> ite Service Technician's ame: ICC Service Technician)nstaller Exp.Date: Manufactureining:I -►5- ►� +�-r12 - - <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: 1tl <br /> Spill bucket nimum 5 gallon <br /> ❑ ❑ electronic Serial#: ourhydrostatic con TS-STS <br /> Elline test ro rammed dwell 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 /> sensor Prima in testing <br /> ❑ ❑ positive shutdown Model: Primary piping 9at: <br /> ❑ fail safe Serial#: ❑ —psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> El fail sate Serial #: <br /> ❑ NA Sump(s) X UST(s) <br /> sensor Te,�ting for the above components are next due by: <br /> ❑ <br /> El positive shutdown Model: ��� <br /> ❑ fail safe Serial #: —�� <br /> Note: Please bs,aware that 2 containment components are required to be tested upon <br /> ElNA 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 /> L n nk <br /> 1 c'. o n m pik <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TME AT EHD'S CURRENT HOURLY RATE. <br /> a=) <br /> H Inspector R:l By Title: � � 'A� <br /> /VL <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />