Laserfiche WebLink
O.PaU I N••.0 <br /> ? r '9 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> CqC` <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s*gov.org/ehd <br /> j5 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facil' Name: Inspection Date:�' 'Z/ <br /> NJ M <br /> 1 <br /> Facility Address: Service Request#: <br /> 9C5 0 , d ro6l�5 <br /> A� A N-U) <br /> � <br /> Onsite Servi a Technician's Name: ICC Service Technician/Installer Exp.Date: Manu curer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> E] line est rogrammed El Caldwell System ❑ Other <br /> sensor <br /> rEl <br /> ositive shutdown Model: �� Primary piping testing at: <br /> ail safe Serial#: ❑ psi <br /> A C i minutes <br /> s nsor U 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 <br /> hid UST acility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> iA Gk S <br /> 5ys 10A pa 4 n <br /> U00 S r.14-040 - crvorkF- <br /> sv & L m Baro <br /> `ns <br /> THIS FACILITY IS SUBJECT TO REINSPItCTION AT ANY TIME AT EHD'S CURRENT HOU Y RATE. <br /> EHD Inspector Received BX: Title: <br /> CVCA f T Xfr:-'-TIrS�ECTIION REPORT <br /> Rev 4/3 2 1 -�>J P <br />