Laserfiche WebLink
o.tcLg c <br /> ? SFE' P SAN JOAQUIN COUNTY <br /> Q: 'a ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> Q��FOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 0,6 —03 — ?4 lZ <br /> Faci tt dress: Service Request#: <br /> Onsite Service Technician's Name: [cc S ice echnici n/Installer Exp.Date: Manufac rer Training: <br /> fd � :. i <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ p <br /> si <br /> ❑ fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Su�np(s) UST(s) <br /> ❑ NA sensor Testing for the a�`lo�v'e compo ents are next due by: <br /> ❑ ❑ positive shutdown Model: 2 (3 <br /> ❑ fa i I 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> lis , 554 On It <br /> WilFly - <br /> THIS FACILITY IS SUBJECT TO REINSPECTION A NY TIME ATRPD:AFURRENT HOURLY RATE. <br /> EHD In ct Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />