Laserfiche WebLink
PgUlty <br />` <br />Leak detector <br />SAN JOAQUIN COUNTY <br />^~� <br />N. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />❑ electronic Serial #: <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />A��FOR� <br />❑ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Nam/ <br />I;�IIJ� <br />- , .,�C_ <br />Leak detector <br />Inspection Date: <br />❑ mechanical Model: <br />� <br />6�Vi� <br />❑ electronic Serial #: <br />A(.1 't -.S <br />Facility Address: <br />❑ <br />Leak detector <br />Service uest #: <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />Or a Service Tec nician's <br />Name: <br />rCC Se ice Technic' /Installer Exp. Date: <br />Manufacturer T fining: <br />L - �_" & , <br />; <br />� <br />P<, i <br />SERVICE <br />- , .,�C_ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line testro ram/�med <br />Receive y' <br />sensor (V rl-A- <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: -� <br />)iFNA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />VThis UST facility is APPROVED to operate <br />SERVICE <br />- , .,�C_ <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />Receive y' <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 20 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />e11 4z, -r -t .& <br />- , .,�C_ <br />- <br />1 Cry U" <br />1,1A <br />THIS F ITY I U JECT TO REINSPECTION.AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins c <br />Receive y' <br />Title: <br />L-71 LA -1 1-1 V - <br />EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 10/06/10 <br />