Laserfiche WebLink
ap4uly. pip, 0 S1+ ---)) Ll I V <br /> ?'��-'•Oc - SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: .1 <br /> ei 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> v Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.s'gov.org/ehd <br /> ,�iF O'IRN`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#:51Z-00--f f—Tj. <br /> i ak �)• nIff <br /> Onsite Service Technician's Name: ICC Se Ice Techniciantinstaller Exp. ate: Manufacturer Training: <br /> 'Job V-12 h Vf n� 1 3 C - <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 13 electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ElOther <br /> sensor —7 <br /> ❑ positive shutdown Model: Primary piping testing at: t* <br /> El El ( I S <br /> fail safe Serial #: i0 psi i/att I Vat�o') <br /> ❑ NA / ` &0 -minutes+ 5oci C_VCt- _ <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑ fall safe Serial #: Note: Please be aware that 2'containment components are required to be tested upon <br /> ❑ NA installation,6 months atter,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 X This UST facility is NOT APPROVED to operate <br /> nyl g� 1 <br /> l 1 <br /> o�t irk r.a1 ymm QJD :3 ' '3C <br /> eek - (OD r�, 6Q sL' <br /> t <br /> 0 o� <br /> V ULA - 'Y s ` <br /> THIS FACII iTN4 IS SUBJECT TO REINSPECTIONAT ANY TIME AT EHD'S CIIIRRENT H URLY RATE. <br /> EHD Inspector: Received B Title: <br /> Fcr'ft%l a 0) <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 <br />