Laserfiche WebLink
.SAN JOAQUIN COUNTY '- <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />-01A101 TVX,c [- 4- Ikv)z!r° <br />3 -k1 -°r7 <br />Facility Address: <br />Service Request #: <br />`�Akko N. TfL" <br />5{L.uo4,97g? <br />Onsite Service Technician's Name: <br />ICC Service Tech nician/EnstaMlr Certification #: <br />Manufacturer Training: <br />mlt-t Jwjc-S <br />2 2-t, c0 <br />W <-V% _ec o <br />SERVICE <br />Leak detector <br />I <br />)C mechanical Model: qCl UD a'0'09' <br />THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br />-T <br />❑ electronic Serial #: o7o310D'i-- <br />l <br />Receiv <br />L <br />❑ line test programmed <br />!a( Leak detector <br />-5mechanical Model: CR (,D 14VO <br />❑ electronic Serial #: 6'510022 <br />�j <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <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 />SERVICE <br />AT Spill bucket )K minimum 5 gallon <br />I <br />XI hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br />-T <br />❑ Caldwell System ❑ Other <br />Receiv <br />L <br />D.E.- Spill bucket It minimum 5 gallon <br />;< 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />D -W • Spill bucket n minimum 5 gallon <br />�j <br />f § 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />1/3/07 <br />A <br />THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br />-T <br />EHD Inspector: 04 NI <br />�AAL <br />Receiv <br />L <br />itle: <br />EHD 23-04 <br />1/3/07 <br />A <br />