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SAN JOAQUIN COUNTY ' <br /> ri cr 'Z <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: -1 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> :P Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 9�/PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> G\X�I <br /> Facility Name: Inspection Date: <br /> KAUAI(w 1%Z&4 09 - I -:� —26 <br /> Facility-Addd]ress: ��'7 yA Service Request#: <br /> Onsite Service Technician's Name: ICC Service Tech ician/Instal er Exp.Date: Manufacturer Training: <br /> Nl&�, ol7sl?� 6�zo <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: ElL11 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: ElPrimaps piping testing at: <br /> El EIElfail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ElElpositive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) ' UST(s) <br /> ❑ NA �/ ���� y �/} <br /> sensor �G Testing for the abgbCOMJ nen a re�41hQy11 <br /> El ❑ positive shutdown Model: <br /> ❑ fail safe /V,� en #:a Note: Please b,aware that 2°containment components are required to be tested upon <br /> NA /t I/ installation,6 months after,and every 36 months thereafter, <br /> i r ube with echanlcaI o erfill at 95/0 ❑ 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 /> f1S1 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ` c11 <br /> l o — <br /> j41144 c�aa ('21d <br /> ygTex Lop <br /> - i <br /> 4 <br /> All S dLT - Ld <br /> THIS FACILITY IS SUBJECT TO REWSPtCT111014 AT ANY TIME AT EHD'S CURRIEN-rHOURLYRATE. <br /> EHD In Receive y: Sitlie: <br /> i <br /> EHD 23-04 V C71 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />