Laserfiche WebLink
SAN JOAQUIN COUNTY <br />Z6 ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephohe: (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 />TfAe- LQ�j 2M— <br />Facilitv Name: inspection Date: <br />-Traw V al e, @ 4eA- <br />Facility AddressLj Service Request #- <br />�' fires IvT �Zpoo 664-6-+- <br />jucm CA <br />Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp. Date: Manufacturer Training: <br />SERVICE <br />-Z—ILeak detector <br />X—mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />(A I Leak detector <br />mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />Sq Leak detector <br />X mechanical Model: <br />0 electronic Serial #: <br />El line test programmed <br />sensor <br />El <br />0 positive shutdown Model: <br />11 fail safe Serial #: <br />0 NA <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />El NA <br />sensor <br />El <br />El 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 />El <br />Overfill prevention (see LG letter 150-1) <br />q*z_W1011# <br />Spill bucket 11 minimum 5 gallon <br />F_] El 1 hour hydrostatic El Incon TS -STS <br />• Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El 0 1 hour hydrostatic 0 Incon TS -STS <br />• Caldwell System El Other <br />— Spill bucket 0 minimum 5 gallon <br />El 0 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />Primary piping testing at: <br />El psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />El Testing for the above components are next due by: <br />Note: Please be aware that 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />El Corrosion protection <br />El I Other: see below <br />0 <br />STWM AZZMAS W 4 N =.a <br />EHD Inspectph Received By, Title: <br />;'y <br />117,1A a 0A ot vl—K (D I <br />EHD 23-04 CUO C _- b UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 - o <br />