Laserfiche WebLink
SAN JOAQUIN COUNTY 14 <br /> l� �-► ENVIRONMENTAL HEALTH DEPARTMENT <br /> I� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sigov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C hevi'ori Scrvice St,,l o?0 1��' 71070/1-Z <br /> Facility Address: Service Request#: <br /> 3�Ss_ E, Hcvomer Lane S R 0o-7-7 0J07 <br /> Onsite Service Technician's Name: ICC Servic Technician/Installer Exp.Date: Manufacturer Training: <br /> yl/1a v Y i 1ryi !k (A l 6 ! <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model:❑ electronicEl El1 hour hydrostatic El Incon TS-STS <br /> Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El El psi <br /> El fail safe Serial#: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that 2'containment components are required to be tested upon <br /> ❑ NA I installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) X Other: see below C,0„vef$ Jan �rfxmef <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ;tet y <br /> Vie (/.hC• ,' ., , ' chor - 'he rn ;t ,n -he ei r' <br /> art IZ r was effoerwe <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: pRecei y: Title: <br /> Ges�� �G�cq�� ✓r <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />