Laserfiche WebLink
O p'•Q'U IN c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Ne.*ad _ je{ 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> ON Telephone: (209 ) 468-3420 Fax: (209) 468-3433 Web: www . sogov. org/ehd <br /> CAS! <br /> Po <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> � G1 � d�lry v1 1r 27 // <br /> Facility Address : Service Request # : <br /> Onsite Service Technician 's Name : ICC Service Technician/Installer Exp . Date : Manufacturer Training : I <br /> 'La � c�GG0 3 ti �1 1 � 5� l0 ?,,o Z1 <br /> SERVICE SERVICE <br /> Leak detectors <br /> ❑ mechanical Model : Spill bucket ( minimum 5 gallon <br /> F1 <br /> ❑ electronic Serial # : 1 hour hydrostatic ❑ Incon TS - STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model : Spill bucket El minimum 5 gallon <br /> F1 El El❑ electronic Serial # : 1 hour hydrostatic ❑ Incon TS - STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor Primary piping testing at : <br /> El Elpositive shutdown Model : Elpsi <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> El El <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 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 /> OPINION <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Gavo f& <br /> A,lkf 1A 4 - U <br /> yrrlit G t ,--a <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO AT ANY TIME AT END ' S CURRENT HOURLY RATE . <br /> EHD Inspector: Received y: Title : <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />