Laserfiche WebLink
oPa�IN••.c <br /> SAN JOAQUIN COUNTY <br /> ar a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/eh <br /> �9�IFpR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> X00 1A?,e-1c-J � ooh <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: M\a1nufacturer Training: <br /> ��1 -•� t`I �. —r l� 5 Q <br /> 3� <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 /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> 3, �s ov/ Primary piping testing at: <br /> ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> >PNA <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 ce aware that 2°containment components are reouired 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) El Other: see below <br /> -�— I--,r- <br /> PHIS CIL_IT IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp Receive By: / Titer <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />