Laserfiche WebLink
I I � <br /> o�q .l.N• <br /> SAN JOAQUIN COUNTY <br /> �-� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �' . •.P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> /FOR <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> r <br /> Facility Address: Service Request#: <br /> C�✓t�I cC o t�" ,-� —7 <br /> Onsite Service Technician's Name: Dice Te_ c� hm1'cien/Installer Exp.Date: Manufacturer Training: <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 <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> El El❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primarypipingtesting at: <br /> ❑fail safe Serial #: p <br /> ❑ NA minutes <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 24 containment components are required to be tested upon <br /> ❑ NA �nstailauon,6 months after,and every 36 months(hereafter <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 /> (+ f f t <br /> �--4- 9Z2 <br /> ;-tr i� _ 1 / �`i G 1 r✓tr_^_._ t.?i.-., Gi r� �F..c,�',. '�'�.-._ lc ,- <br /> --Z <br /> „ - r —7 , <br /> ( h 3 <br /> THIS FACILITY IS SUBJECT"Tb REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />