INSTALL_2020 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468m3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: v � Leak detector Facility Address: ❑ Service Request #: U) { elssS eoor% 1 o t / h 52O r 08512-g7 ❑ line test programmed Onsite Service Technician's Name. ICC Service Technician/installer Exp. Date: Manufacturer Training: ❑ mechanical Model: ❑ SERVICE Spill bucket ❑ minimum 5 gallon ❑ El1 hour hydrostatic ElIncon TS -STS ElCaldwell System ElOther Spill bucket Elminimum 5 gallon ❑ El1 hour hydrostatic ElIncon TS -STS 1:1Caldwell System ElOther Primary piping testing at: L0 minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months atter, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below El SERVICE v � Leak detector ❑ ❑ mechanical Model: U) { elssS eoor% 1 o t / h ❑ electronic Serial #: ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: TO REINSPECTION AT ❑ NA Received By: tTo v It ?L1 sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA _ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT v � 87 cyl dlt�a I / 2 far rr U) { elssS eoor% 1 o t / h S .. THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHDjnspector: Received By: tTo v It ?L1 J u De a Title: IP.� EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT