Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> W: X <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> it�-4;�Cm AAA- <br /> NI <br /> Facility Address: Service Request#: <br /> VA <br /> 107" Yv <br /> Onsite Service Technician's Name: [CC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> J 4-3cp 10 1%,0 6 114, �ML 0 16-7-03 ! ®® <br /> SERVICE SERVICE <br /> Leak detector -Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial: <br /> 0 Caldwell System E-1 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial: <br /> El line test rogrammed 0 Caldwell System 0 Other <br /> p <br /> Leak detector -Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: <br /> El line test rorammed El Caldwell System 0 Other <br /> pg <br /> sensor ❑ Primary piping testing at: <br /> El 0 positive shutdown Model: psi <br /> 0 fail safe Serial #: minutes <br /> 0 NA <br /> sensor Secondary containment testing for: <br /> El 0 positive shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial#: Sump(s) UST(s) <br /> 0 NA sensor El Testing for the above components are next due by: <br /> El 0 positive shutdown Model: <br /> 0 fail safe Serial#: Note: Please be aware that 2*containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> El Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) Other: see below <br /> &0--A QA Cain �m Gong, Caffi^�Jjov, UACJWM (AID4, --e,- <br /> I <br /> l r W - <br /> wiUjrS 6-0 AV,\-Ai. 6,� 19' <br /> a" 4 Al <br /> &abZft4,e� -719 /uat (44A4&j" 041� Cdn <br /> Con ffn�� W4[�hd�A^A <br /> THIS FACILITY IS SUBJECT TO REINS RECION AT ANYTIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Inspector: ive By: Title: <br /> OLT <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />