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10/05/2009 MON 11:29 FAX 2094683433 SJC EHD 14001 ********************* *** FAX TX REPORT *** ********************* TRANSMISSION OR JOB NO. 2930 DESTINATION ADDRESS 914082136012 PSWD/SUBADDRESS ICC service Techn cian/lnstaller Certification #: DESTINATION ID ST. TIME 10/05 11:27 USAGE T 01'33 PGS. 1 RESULT OK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN'r 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fur: (209) 468-3433 Web: wwwAgovoreehd 1TNT1FRr:RC111ND STORAGF TANK (UST) PROGRAM SERVICE REQUEST INSPECTION RF,PORT F 'lity Name: Inspection Date: Facility Address: NOV w Service Request #- Onsite Service Technician's Name: ICC service Techn cian/lnstaller Certification #: Manufacturer Training: - o N& A) SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% H❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below