Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ONVIRONMENTAL HEALTH DEPARTMENT <br />9 <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Leak detector <br />❑ <br />Facility Address: <br />Service Request #: <br />Onsite Service Technician's Name: <br />�' , <br />ICC Service Technician/Installer Exp. Date: <br />-7 <br />Manufacturer Training: <br />VIL �,i <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 />}'I 11 HL'RI"1 <br />❑ electronic Serial #: <br />❑ <br />line test programmed <br />EHD Ins ctor: <br />q/ - sensor <br />El/positive shutdown Model <br />❑ f* safe Serial #: G <br />A <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 />'� This UST facility is APPROVED to operate <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 />}'I 11 HL'RI"1 <br />Primary piping testing at: <br />❑ <br />psi <br />EHD Ins ctor: <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° containment components 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 />rEl <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />p�^l rL ' <br />}'I 11 HL'RI"1 <br />TH FAC LITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins ctor: <br />Received <br />Title: <br />7B <br />EHD 23-04 U v y UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />