Laserfiche WebLink
PgUl�y <br /> �o.• -: '' •.co SAN JOAQUIN COUNTY <br /> y; '2� ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.orCI <br /> UNDERGROUND STORAGE TANKK (UST) PROGRAM SERV <br /> ICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facili Ad ress: Service Request#: <br /> W7 Ea�L Wlr7v) rPms�ffl <br /> Onsite Service Technician's Name: ICC Se ice Tech n I ciariffnIstaller Exp.Date: Manufacturer Trainin : <br /> SERVICE SERVICE <br /> Leak detector Spill bucket t minimum 5 gallon <br /> - El ❑ mechanical Model: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System Other <br /> El line test programmed iW <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ ❑ positive shutdown Model: El psi piping testing at: <br /> ❑ fail safe Serial#: p <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 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 /> [101 Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to op rat ❑ This UST facility is NOT APPROVED to operate <br /> UN- on AA <br /> o pt <br /> rfia <br /> Tv, <br /> s.. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I sp or: I Re ved By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />