Laserfiche WebLink
Q¢quly_ C PR. 0 5 g <br /> �''�t •'OZ SAN JOAOUIN COUNTY <br /> c a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hakelton Avenue, Stockton, CA 95205-6232 <br /> ., Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd <br /> 4C%FO'RN`� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Adds: .Service equest#: <br /> 0A- �6clop S.Pr-ooq l-T <br /> Onsite Service Technician's Name: ICC Service TechnicianAnstaller Exp. Date: Manufacturer Training: <br /> KJOV —1 -30- . <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed y <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed y <br /> sensor <br /> El ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ _ <br /> ❑fall safe Serial #: psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA 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 /> a: aLtA . GNb ►o •I�l <br /> 3a STP - 11. 3 f 1 4 3 C (IL-11i) <br /> !!5. 2> ' 5', <br /> SCOL b y", z 2.5 W b/k VWVQ-dl cw r..t-eli-,LL/t C� <br /> Mod <br /> THIS FACILITY IS SUBJECT TO REINSPECT ON 4T ANY TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Inspector: n Race' ed y: Title: <br /> ri` Vv11 ,9�yvk.(AA <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />