Laserfiche WebLink
°t'�u I y' c • • <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w. < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.s*gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> na-m)-- --.-641 l / <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: ElElSpill bucket ❑ minimum 5 gallon <br /> F-1 El 1 hour hydrostatic Incon TS-STS <br /> E-1 electronic Serial: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> [I positive shutdown Model: <br /> El ❑ fail safe Serial #: El psi <br /> ❑ 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 20 containment components are required to be tested upon <br /> ❑ NA Iinstallation,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 /> "i t a- 1 <br /> ✓j� tat./ v� <br /> �..� 'r div.! 5 �.— t-i'�r-t 5r1 Gt.✓tl�i-cs �,.�.. <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO AT ANY TIME AT END'S CURRENT HOfjRLY RATE. <br /> EHD Inspector- Receive Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />