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a.�qu I!Y••.e <br /> �• � •0 SAN JOAQUIN COUNTY <br /> 2 �~ ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> SRH FOOD & GAS Wednesday, June 9, 2010 <br /> Facility Address: Service Request#: <br /> 749 E CHARTER WAY, STOCKTON SR0060071 <br /> Onsite Service Technician's Name: ICC Service Tech nicianllnstaller Exp.Date: Manufacturer Training: <br /> GAVIN WILLIAMS 08/09/10 VEEDER ROOT=8120110 <br /> SERVICE SERVICE <br /> Leak detector <br /> '-ium 5 gallon <br /> E] ❑ mechanical Model. ❑ QTS <br /> TS <br /> Serial#: ❑ <br /> ❑ line test programmed <br /> Leak detector <br /> ® allon <br /> ElElmechanical Model: _ <br /> ❑ <br /> Elelectronic Serial#: 7 <br /> ❑ line test programmed ❑t t_I ,`Fi fit.. ;Ftf9 <br /> Leak detector t. :F I.i_I;; ih9tJLiL;i' <br /> mechanical Model: allon <br /> ❑ El ❑ 1 l LIL1- i 9Li1151v1 q:X17I°I 3 <br /> ❑electronic Serial#: ❑f 7UIi q, "'Ot u <br /> ❑line test programmed <br /> 89 ANN sensor <br /> 11 positive shutdown Model:VR 794390-407 Prir <br /> fail safe Serial#: 734532 ❑ — <br /> ❑x NA — <br /> sensor Sec <br /> ❑positive shutdown Model: <br /> ❑ ?Iping <br /> ❑fail safe Serial#: <br /> _ 3T(s) <br /> ❑NA ❑ <br /> sensor Test ext 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 /> ❑ Overfill prevention (see LG letter 150-1) ElOther: see below <br /> ONSITE TO VERIFY FUNCTIONALITY OF THE REPLACED 89 MIDGRADE ANNULAR SPACE <br /> SENSOR. SENSOR FUNCTIONED NORMALLY WHEN TESTED. PULL STRING SHOULD BE <br /> REPLACED AT A LATER TIME. SUBMIT FORM C FOR PERMIT TO BE COMPLETE. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHlX,WytP to: � ]o� ! Receive By: Title:y� <br /> EHU 2304 ``l Ij UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 06101110 <br />