Laserfiche WebLink
ORQUI/y Q <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y' 'X 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> �aGl POR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Ma ufa turer Tai n <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El E-] 1 hour hydrostatic ❑ Incon TS-STS <br /> E-] electronic Serial#: ❑ Caldwell System E] Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: p <br /> F­1 ❑ fail safe Serial#: El <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ® ❑ positive shutdown Model: _UDC(s) Piping <br /> ❑ fail safe Serial#: jav 11 Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the aboveco ponents are next due by: <br /> ❑ ❑ positive shutdown Model <br /> ❑ fail safe Serial#: Note: Please a aware that 2°containment components are required to be tested upon <br /> ❑ NA 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) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPEC ION AT NNY TIME ATHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rce' e y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 �� <br />