Laserfiche WebLink
Rquly <br /> SAN JOAQUIN COUNTY <br /> Q - Gla ENVIRONMENTAL HEALTH DEPARTMENT <br /> W:_ ie` 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.ora/ehd <br /> UNQD�E�FROtGj�RUND STORAGE TANK <br /> NK (UST) PROGRAM SERVICE REQUEST INSPECTION <br /> TION REPORT <br /> Facility Name: Inspection Date: <br /> t 6 <br /> Facility Address: Service Frequest#: <br /> J <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> i j� #R,30,5-2 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ 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: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: LIDC(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 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 /> C4 Aeii, <br /> S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe r: Receiv By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />