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TRANSMISSION VERIFICATION REPORT <br /> TIME 09/04/2013 14: 17 <br /> NAME SJC EHD UNIT 3 <br /> FAX ^094683433 <br /> SER. # BRO117F534354 <br /> DATE,TIME 09/04 14: 17 <br /> FAX NO. /NAME 912094654988 <br /> DURATION 00: 00: 33 <br /> PAGE(S) 01 <br /> RESULT OK <br /> MODE STANDARD <br /> SAN JOAQUIN COUNTY <br /> r - -tNVIRONMENTAL HEALTH DEPARTMENT"— <br /> yr <br /> ;:. .. '. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: inspection Date: <br /> Cru ` ers it 2-q $ - 152-o 1.3 <br /> Facility Address: Service Requost#: <br /> i13-4 W, frog 00 -:I-+�g 2- <br /> Onsite Service Technician's Name: ICC Service TechnlcienAnstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector. Spill bucket p minimum 5 gallon <br /> El <br /> ❑ mechanical Model: El u 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #:w_ Cl Caldwell System E! Other <br /> El line test ra rammed _ <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> ❑ <br /> El mechanical Model: ❑ 0 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #, _ _.. ❑ Caldwell System 0 Other <br /> Elline test ro rammed <br /> sensor <br /> Mpositive shutdown Model: 3 g d ' S ❑ Primary piping testing at: <br /> ail safe Serial #: A-k_ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positi e shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sumps) _„_ UST(s) <br /> O NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fail safe Serial #. N04W Pleaaa"A aware that T UNitairwntnt components ars rmgOred to be tested upon <br /> ❑ NA irWtallalicxr,P rnvrrtha after.and every 30'nantha 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 />