Laserfiche WebLink
INVIRONMENTAL <br /> SAN JOAOUIN COUNTY <br /> HEALTH DEPARTMENT <br /> i 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> V.. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> q<1 FORM% <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Dale: <br /> 101 za '�9C�� /0/2 a�/ Fr <br /> Facility Address: Service Request#: <br /> �ZV2P W.; W 00-AGI-7 <br /> Onsite Service Technician's Name: ICC erv7ie Technician/Installer Exp.Date: Man act rer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket minimum 5 gallon <br /> ❑ ❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket minimum 5 gallon <br /> El ❑ electronicSerial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El System Other GZY21. � <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> ❑ <br /> El fail safe Serial #: ❑ psi <br /> El 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 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 /> S� eneS' <br /> e Q� <br /> Vf:n lti��d d&dM dn' &2e-z tSi�?,f fn& <br /> THIS FACILITY I JECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: -- ed�y: Titl <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />