Laserfiche WebLink
OPQU IN'•.0 <br /> SAN JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> y > !, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' • P Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> AD C rod--l r/��� /�`: ��'�� -1/t i s <br /> Facility Address: Service R quest#: <br /> "7/,-D /VLI 5W00-7/ <br /> Onsite Service Technician's Name: ICC Servic chnici ns alter Exp.Date: Manufacturer Training: <br /> 10Z x- Z vWx.L it ►v, <br /> SERVICE SERVICE <br /> ` Leak detecto a2 J Spill bucket El minimum 5 gallon <br /> El mechanical Model: yuh) Pxo-F- + f ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> Xelectronic Serial #: 5-6-72 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> . sensor 1 <br /> ❑ ositive shutdown Model: VR0dW9M— Primary piping testing at: <br /> ❑ psi <br /> ❑ fail safe Serial #: <br /> El NA minutes <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 /> ❑ NA Iinstallation,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 /> rEITOverfill 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspectors- }� ceived By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />