COMPLIANCE INFO_2001-2009 - Laserfiche WebLink

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SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTME i 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjjzov.orjz/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: SERVICE Inspection Date: OY&M 1 101�-/°-) Facility Address: Service Request #: q 9 S 616 59400S170-7 Onsite Service Technician's Name: ICC Service Technician/installer Certification #: Manufacturer Training: &"(z `16 - OT I/M.T a /719z- 2kZ SERVICE detector ❑ j-Leak chanical Model: qq 0 Z66 c) Er ❑ electronic Serial #: 0661156 [ -7 ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed 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% EODrop 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 THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other [ -7 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ 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 Cd 0 ti THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector:&/M.Title: D-,1, [ -7 1 EHD 23-04 C// / Rev 06/22/07 /