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OP�uIN• C <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Kwik Sery - Tracy Tuesday, August 17, 2010 <br /> Facility Address: Service Request : <br /> 950 W. 11th St., Tracy SR0060726 <br /> Onsite Service Technician's Name: ICC Service Technicianflnstaller Exp.Date: Manufacturer Training: <br /> Gavin Williams 8/6/12 VR x. 6/30/12 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: El 1 hour hydrostatic ❑Incon TS-STS <br /> D Caldwell System ❑Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket D minimum 5 gallon <br /> ❑ ❑mechanical Model: ❑ ❑1 hour hydrostatic ❑Incon TS-STS <br /> ❑electronic Serial#: ❑Caldwell System ❑Other <br /> D line test programmed <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ ❑mechanical Model: ❑ 111 hour hydrostatic ❑Incon TS-STS <br /> ❑electronic Serial#: ❑Caldwell System ❑Other <br /> D line test programmed <br /> Dsl Annular sensor <br /> 0positive shutdown Model: VR 794390-409 Primary piping testing at: <br /> Nfail safe Serial#: 835573 ❑ minutes <br /> ❑NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑positive shutdown Model: UDC(s) Piping <br /> Dfail safe Serial#: Sump(s) UST(s) <br /> ❑NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El ❑positive shutdown Model: <br /> ❑fail safe Serial#: Note: Please be aware that r 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) ❑ Other: see below <br /> 835573 to verify functionality of diesel annular sensor. Passed. Verified length at 192.5 inches. <br /> THIS FA ILITY IS ECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins o Recei By: o Title: <br /> EHD 2304 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 06/01/1 o <br />