Laserfiche WebLink
°P0.uiN' c • <br />SAN .JOAQUIN COUNTY <br />Q' -+ ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.or /eg hd. <br />�4�ikoa��P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />—1 <br />Inspection D te: <br />to <br />Facility Address: <br />Se ice R(/quest #: <br />rl7O 1.0�•-7�b� — /Z I? <br />cZDSr 2r 7 cD <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />❑ <br />— Z- 1 <br />❑ <br />L–) <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />I— <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />_ sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Seria! #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />_ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />_ Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />I— <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 20 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />�,// <br />4 LS�_ 0(_ <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/171/08 v <br />�V,,FJCILITY IS SUBJECT 7.0 REINSPECTION A .ANY TIME AT EHD'S CURRENT HOURI-Y RATE. <br />EHD I pe r <br />Recei B e: <br />�C { C l� <br />�,// <br />4 LS�_ 0(_ <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/171/08 v <br />