Laserfiche WebLink
O.;AU IN'•.0 <br /> SAN JOAQUIN COUNTY <br /> c. 'a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Art is 4 [3 <br /> Facility Address: Service Request#: <br /> L_1V 0066,04 <br /> Onsite Service Technician's Name: ICC Service Technic <br /> /installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> F] ❑ electronic Serial:: L-1 El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed El Caldwell System F1 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 <br /> ❑ <br /> El shutdown Model: ElPrimarppiping testing at: <br /> si <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 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 /> 414P�f 01 N6n'T(+ F[PO ONQ <br /> 0 'P, , <br /> S�Prr - vi <br /> bbL o see <br /> I OK 7h ow"fel <br /> esz( s <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD In r: Received y: Title: <br /> �v 2 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />