Laserfiche WebLink
oAqulN• c <br />?•'��' a� SAN JOAQUIN COUNTY 16 <br />Q Z� ENVIRONMENTAL HEALTH DEPARTMENT <br />y' t 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />A�/FORS <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Dame: <br />Inspection Date: <br />�0 36�t1 <br />1 s <br />Facili y Address: <br />Service/Request #: <br />%21 d4 <br />S� (00 5 -7 6� <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manruffaacct\ureLZinin'y—,-A,.,— <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REI SP N ATA Y TI AT D'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />d B <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <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 />❑ <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />q1 Spill bucket ,�? minimum 5 gallon <br />'01 hour hydrostatic T'yncon TS -STS <br />THIS FACILITY IS SUBJECT TO REI SP N ATA Y TI AT D'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />d B <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 />Primary piping testing at: <br />❑ <br />psi <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 20 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 />❑ <br />Other: see below <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />THIS FACILITY IS SUBJECT TO REI SP N ATA Y TI AT D'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />d B <br />Title: <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />