Laserfiche WebLink
i <br /> O P'' U• • N' • .0 <br /> i� SAN JOAOUIN COUNTY <br /> Q: a ENVIRONMENTAL HEALTH DEPARTMENT <br /> Lu <I <br /> i�'� (' r /1 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> \` . Telephone : ( 209 ) 468 - 3420 Fax: ( 209 ) 468 - 3433 Web: www . sigov . org/ehd <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name Inspection Date : <br /> lJ JI � � <br /> Facility Address : Service Request # : <br /> Onsite Service Technician ' s Name : ICGSem4ea 7" hnician/Installer Exp. Date : Manufacturer Training : <br /> V, Q ( : - PSI/ N <br /> SERVICE SERVICE <br /> Leak detector <br /> 11 mechanical Model : Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial : ❑ El hour hydrostatic ElIncon TS - STS <br /> ElCaldwell System ❑ Other <br /> ❑ line test programmed <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 <br /> sensor <br /> E-1 ❑ positive shutdown Model : ❑ Primary testing at : <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA <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 /> ❑ ❑ positive shutdown Model : <br /> ❑ fail safe Serial # : Note: Please be aware that 20 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 /Ia <br /> ❑ This UST facility is APPROVED to operate L This UST facility is NOT APPROVED to operate <br /> i a 44 ed?A 0 V Piiu• o � U <br /> ee. in IAA <br /> alpa LO loo\ , r J401 IA .D <br /> WCO �O r S <br /> T IS FACILITY IS SUBJECT TO REINSPEC= OWAI ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD In or: ReceivedB /� Title : /( <br /> a. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/ 12 <br />