INSTALL_2019 - Laserfiche WebLink

Home Browse Search

SAN aJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 46&3420 Fax: (209) 46&3433 Web: www.;)jgov:org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: r Inspection Date: ❑ ❑ 1 hour hydrostatic ❑ Incon T&STS Leak detector ❑ Caldwell System ❑ Other ❑ ❑ mechanical Model: Facility Address: electronic Service #: ❑ psi (,Request je0 4 `i I Leak detector ❑ t onniit{ Technician's Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: ❑ tService � \/t i Uh by /( ❑ line test programmed ❑ Corrosion protection sensor ❑ This UST facility is APPROVED to operate SERVICE SERVICE ❑ ❑ 1 hour hydrostatic ❑ Incon T&STS Leak detector ❑ Caldwell System ❑ Other ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ psi ❑ line test programmed minutes Leak detector ❑ ❑ mechanical Model: Testing for the above components are next due by: ❑ electronic Serial #: installation, 6 months after, and every 36 months thereafter. ❑ ❑ line test programmed ❑ Corrosion protection sensor Other: see below ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: l ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ AT ANY TIME AT EHD'S Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon T&STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon T&STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secon ary containment tes In for: j V PTf UDC(s) q( I Piping Sump(s) UST(s) 1 Testing for the above components are next due by: Note: Please be aware that 20 containment components are required to be tested upon 0,04(2 1 y installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below This UST facility is NOT APPROVED to operate V EHD 23-04 )U 1 0,04(2 1 y W ISG~ i l ! THIS PACILITY IS S Rj T Tb REfINSPEICTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspe tor:p� �y 1� V Received By: Title,:: C, J �A 1 1 Val�t�(Q1 Rev i UST SERVICE REQUEST INSPECTION REPORT 4/30/12