COMPLIANCE INFO_2004-2007 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.si2ov.org/ehd UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: 30 O Facility Address: Service Request#: Onsite Service Technician's Name: IService Techmcian/Installer Certification#: Manufacturer Training: \TAV 1> 13U �21 � SERVICE SERVICE Leak detector Spill bucket ❑ minimum 5 gallon ❑ ❑ mechanical Model: 640:7 ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS ❑ electronic Serial#: ❑ Caldwell System ❑ Other ❑ line test programmed Leak detector Spill bucket ❑ minimum 5 gallon ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS ❑ electronic Serial #: ❑ Caldwell System ❑ Other ❑ line test programmed Leak detector Spill bucket ❑ minimum 5 gallon ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS ❑ electronic Serial #: ❑ Caldwell System ❑ Other ❑ line test programmed ql MAJWVsensor !fositive shutdown Model: 77 Y,3 y 0 —(10 Primary piping testing at: ail safe Serial #: (,Z2� ❑ psi minutes El NA sensor Secondary piping testing at: ❑ ❑ positive shutdown Model: ❑ psi 1:1 fail safe Serial #: minutes ❑ NA sensor Secondary containment repairs for: ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping ❑ fail safe Serial#: Sump(s) UST(s) ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below Ut4o' s P THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: �j Received B Title: • r'I C ✓��t�i �� EHD 23-04 Rev 06/22/07