Laserfiche WebLink
�' •E� •o� SAN JOAQUIN COUNTY <br /> �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.s'gov.org/ehd <br /> FORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> /- <t� - 9- <br /> Facility Address: 11 Service Request#: <br /> jjjt <':�. C Cj k- 6 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> --------------------------------------- <br /> SERVICE SERVICE <br /> Leak detector � Spill bucket 1341nimum 5 gallon <br /> F-1 ❑ mechanical Model: d Chour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> Leak detector <br /> ❑ mechanical Model _ Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System 11 Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <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 2°containment components are required to be tested upon <br /> El 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 /> 1 � / // <br /> THIS FACILITY IS SUBJECT TO REINSPECTION A ANY ME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp t r:h i Received By: Title: <br /> EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />