Laserfiche WebLink
SAN JOAQUIN COUNTY <br />OVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazeiton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date - <br />Facility Address: Service Request <br />0 <br />Name: ICC Service Tech n ician/Installer Exp. Date: i Manufacturer Training: <br />nsite Service Technician's <br />trik <br />El This UST facility is APPROVED to operate D This UST facility is NOT APPROVED f6operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />Leak detector <br />❑ <br />71 mechanical Model: <br />7-, electronic Serial #: <br />El line test programmed <br />El <br />Leak detector <br />El <br />El mechanical Model: <br />El electronic Serial #: <br />❑ <br />0 line test programmed <br />i <br />sensor <br />[1 positive shutdown Model: <br />Ll fail safe Serial #: <br />F1 NA <br />sensor <br />❑ positive shutdown Model: <br />El fail safe Serial #: <br />El NA <br />El <br />sensor <br />El <br />11 positive shutdown Model: <br />0 <br />El fail safe Serial #: <br />El NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />0 <br />Drop tube with mechanical overfill at 95% <br />0 <br />Overfill prevention (see LG letter 150-1) <br />El This UST facility is APPROVED to operate D This UST facility is NOT APPROVED f6operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />Spill bucket E- minimum 5 gallon <br />❑ <br />El 1 hour hydrostatic El Incon TS -STS <br />[I Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />El 1 hour hydrostatic El Incon TS -STS <br />El Caldwell System El Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Sec I y Containment testing for, <br />UDC(s) Piping <br />Sump(s) UST(s) <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 rcrLths thereafter. <br />El <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />0 <br />Other: see below <br />El This UST facility is APPROVED to operate D This UST facility is NOT APPROVED f6operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />