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DEC-23-2009 11 :50 AN GETTLER-RYPN INC. 925 551 4770 P. 04 <br /> r <br /> 411i1, �f SAN JOAQUIN COUNTY <br /> -ter-... Zt <br /> <� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 60C East Main Street, Stockton, CA 95202•3029 <br /> r. <br /> 1,10101 (209)468-3420 Fax: (209)468-34'13 web: v✓ww_sj9ov. ehd <br /> ql�k a�`5'y <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: ______ �— <br /> -� .r Inspection Dale: <br /> Facility Address: <br /> ! - Ser vlcoo Request tt: • —'—`-- — <br /> 41 <br /> Onsite Service Tachnicianrs Name: ICC Servire Technician/Installer Exp.bateM�ure�rY <br /> Training: <br /> vcr <br /> SERVICE SERVICE <br /> Leak detector — <br /> C 1 mechanical ModelCJ 1 Spill bucket minimum 5 gallon <br /> ` ❑ electronic Serial -'` '- ' C3 : hour hydrostatic f"1 Incon TS-STS <br /> fl: ___ __ __ <br /> 11 line test programmed — I Cadwell Systern 171 Other <br /> Leak detector --- - — <br /> I 1 mechanical Model: w _ I Spill Ducket L'! minimum 5 gallon <br /> ❑ electronic Serial #: _ "`- J 1`i 1 heur hydrostatic n Incon 1•S-STS <br /> ❑ line test programmed -" -- Ei Caldwell System r:] Other <br /> Leak detector <br /> U mechanical Model: -�_ _ Spill oucket ❑ mimmum 5 gallon <br /> C' electronic Seral N: --- I I I I hour hydrostatic r'I Incon TS-STS <br /> line test pro rammed -1 Caldwell System El Other <br /> ---Sensor - ... -- <br /> I; positive shutdown Model: —� — — Primary piping testing at: <br /> f._1 fail safe Serial #: <br /> n NA -.... _ minu,es <br /> sensor Secondary containment testing for: <br /> ❑ R positive shutdown Model: -- UDC(s) _ piping <br /> El fail safe Seral #: -- --Sumps1 NA - UST(s <br /> ) <br /> sensor I ' i 'Testing for tie above components ere next due by: <br /> positive shutdown Model: <br /> 0 fail safe Serial # <br /> Oy:Y' '^[onn ne uv;:en lnar./'CnnWmlf:Cnl rertpmn«'K am M'i:dral+:Ri l+dn�.pr:n <br /> 11 NA �--- `�•-•.___._—._____-_._ .:�.:.iner., , �..a mr:: snn nwry 3Frmnrn••rlmrrnnnr <br /> Cl _ Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> ❑ -___ Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> C1 Overfill prevention (see LO letter 150-1) (7 Other: see below �— ---- _—n_ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. —— <br /> ENDlnspeaoL.,� Receiverlay: <br /> .' hnn. <br /> Eric 2.1-04 ..'iT 5001R.4- :0 <br /> I:P::;!E o- Iii=!'G hG4 R�PfjF:: <br /> 4" lir-•%06 <br />