Laserfiche WebLink
UI0 9 <br />PQ �• <br />SAN JOAQUIN COUNTY <br />Q yA ENVIRONMENTAL HEALTH DEPARTMENT <br />y? ` 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />'9(jFORC, <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />Leak detector . <br />❑ <br />Facility Address: I <br />Service Request #: <br />( .S so N Pr� u -E <br />S K D O L 11 "7 <br />Onsite Service Technician's Name: ICC Service Technician{�sytalier Exp. Date: <br />Manufacturer Training: <br />�A23w�S 2�1-7� lZ <br />JAN 5Z G32U "Ir 12 <br />❑ <br />SERVICE <br />Leak detector . <br />❑ <br />❑ mechanical Model: <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT Y TIM T EHD'S CURRENT HOURLY RATE. <br />❑ electronic Serial #: <br />Received By: <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 />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT Y TIM T EHD'S CURRENT HOURLY RATE. <br />❑ Caldwell System ❑ Other <br />Received By: <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 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />dktAA i5 b L0 Z- t91 0 <br />CJ — b <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT Y TIM T EHD'S CURRENT HOURLY RATE. <br />EHD Inspect: M� <br />Received By: <br />Titlq�r , / <br />wD 23-04 <br />v 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />