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9255517888 Line 1 14:58:34 06-13-2011 2/3 <br /> SAN JOAQUIN COUNTY <br /> X 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 /> 7 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> • <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 44 <br /> Onsite Service Technician's Name: [CC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 17 Z, Ok I/121111 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> EJ El mechanical Model: C1 0 1 hour hydrostatic El Incon TS-STS <br /> 11 electronic Serial El Caldwell System El Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> ❑ El mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial: <br /> El Caldwell System 0 Other <br /> El line test programmed <br /> I/ sensorPrimary piping testing at: <br /> 2!Pp6sitive shutdown Model: J/z <br /> email safe Serial ­7 ❑ psi <br /> 0 NA minutes <br /> — sensor Secondary containment testing for: <br /> El El po'sitiv6 shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial Sump(s) UST(s) <br /> 11 NA sensor El Testing for the above components are next due by: <br /> ❑ El positive shutdown Model: <br /> Ofail safe Serial Note: Please be aware that 2*containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical Overfill at 95% El Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other see below <br /> ,� This LIST facility is APPROVED to operate El This LIST facility is NOT APPROVED to operate <br /> THIS ACILUTY IS/SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> /�� <br /> I R Title.- <br /> �%!8t -WEHD Iceived By:/1 1 ( <br /> SHD 23-04(_,-_//// UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06110 <br /> J <br />