Laserfiche WebLink
SAN JOAQUIN COUNTY <br />;G <br />3 ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /g ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />-e <br />Onsite Service Technician's Name: ICC Service <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />El This UST facility is APPROVED to operate <br />maps = W10 <br />U THIS' FACI <br />EHD Inspe <br />t <br />EHD 23-04 <br />Rev 4/30/12 <br />�.Wffl< <br />Installer Exp. Date: Manufacturer Training: C) 3 <br />—1 <br />_1 ae1A K10A <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testi g for: �, t l* <br />`' <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />o _ ' r) Uv <br />Note: Please be aware that 2° containment Omponents are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />ri71� ' <br />1� ' 3 ► tl K0 . ` ,.W.4 <br />e a rCURRENT <br />