Laserfiche WebLink
or SAN JOAQUIN COUNTY <br /> •fir''. <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205 6232 <br /> Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.s6gov.or /q ehd <br /> �IFORH <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: - Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <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 /> 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 <br /> ❑ ❑ positive shutdown Model: Primary piping testing <br /> ❑fall safe Serial#: ❑ —psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> 11 positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: (s)SumpUST(s) <br /> ❑ NA ( ) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: <br /> ❑ NA Note: Please be aware that r containmentom <br /> cponents are requireU to be teslaot upon <br /> installation,6 months aber,arM every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95%p ❑: 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. Re B : r---� <br /> > Y- C ;t Title: <br /> EHD 23-04 <br /> Rev 4130/12 UST SERVICE REQUEST INSPECTION REPORT <br />