Laserfiche WebLink
OPquln!. C <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> _ Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> C9�iFOR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspe on Date: <br /> " ft Pm Oa-t`7— �a <br /> Facility Address: Service Request#: <br /> s 006la44 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> AY1'Kn.QY► .Let134 laillai <br /> d l2 <br /> SE ICE SERVICE <br /> Leak detector <br /> 11 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El 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 /> ElElpositive shutdown Model: p <br /> si <br /> ❑ fail safe Serial#: ❑ minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ <br /> El positive shutdown Model: r UDC(s) (?ytp" SV <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor K .Trstft <br /> V1 r they: <br /> ❑ <br /> 11 positive shutdown Model: ►ny `� I^te <br /> ❑ fail safe Serial#: Note: Please be aware that 2°containment components are requirf bee <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 /> El 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 /> t I bcw�e <br /> Test- a Glov►3- S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD e or: Recoveo B t Title: <br /> e� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />