COMPLIANCE INFO_1999-2009 - Laserfiche WebLink

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SAN JOAQUIN COUNTY *NVIRONMENTAL HEALTH DEPARTMENT* 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility name: Inspection Date: �lArv� AA m I 12 1 6 Facility address: 13 D t W' V e 44 lcej Aj Ldd; Service request number: S 1Z OoL-j 8 gbh Name of Service Technician performing tests: ICC Service Technician/Installer certification #: SZ 14 RS- 76 - UT Manufacturer training: veer' eco % r Leak detector ❑ SERVICE Leak detector ❑ ❑ mechanical Model: P54 �� 1 ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed 70[q,/- sensor ❑ ❑ positive shutdown Model: 'fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS P54 �� 1 ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS Y TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below C P54 �� 1 4n4 ty� THIS FACILITY IS SUBJECT TO REINSPECTION A Y TIME AT EHD'S CURRENT HOURLY RATE. EHD In ctor: I ReRived By: v /v� Title: �1-ex'�Texl