COMPLIANCE INFO_2009-2015 - Laserfiche WebLink

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OpQuI•N• C SAN JOAQUIN COUNTY 10`ENVIRONMENTAL HEALTH DEPARTMENT N._600 East Main Street, Stockton, CA 95202-3029 Y. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd 9�4iORS UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: , Inspection Date- Facility Address: ,� ' Service Request #: Onsite Service Technician's Name: n ICC Service Technician/Installer Exp. Date: Manufacturer Training: SERVICE CM Leak detector )�1 mechanical Model: Lo ❑ ❑ electronic Serial #: ❑ line test programmed THIS FACILITY IS UBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ 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) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other THIS FACILITY IS UBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate AyI&L THIS FACILITY IS UBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: Recelvved N. X Title: E H D 23-04 Rev 10/06/10 UST SERVICE REQUEST INSPECTION REPORT