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(9/09/2010 THU 13: 14 FAX 20 13433 SJC EHD Henderson Maint Co 0001/001 <br /> r:90 <br /> uay <br /> �.coG SAN JOAQUIN COUNTY <br /> : j ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone;(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.or / <br /> (7.Poe •P <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility A dre s: (� Saarrviic Request#: <br /> _77oo f/Ir�w1G,-c.Y r�cff- �� ar /1�ofl A 0,6 t <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> rb V A 1av�-( �- GtLrr-, <br /> 3 olio <br /> r„„ � J <br /> t <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ O 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 /> ❑ O mechanical Model: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> O electronic Serial#: ❑Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ ❑mechanical Model: ❑ ❑ 1 hour hydrostatic O Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System ❑Other <br /> C line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑positive shutdown Model: J psi <br /> ❑fail safe Serial#: minutes <br /> ❑NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑positive shutdown Model: UDC(s) Piping <br /> O fail safe Serial#: Sump(s) UST(s) <br /> ❑NA n <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑positive shutdown Model'. <br /> ❑fail safe Serial#. Note:Please be aNaw Ihet 2°coN&mmom owponenls are roquYed to be:BS:90 upon <br /> 0 NA instaralion,6 rranUNs atter,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 /> THIS FACILITY IS BJECt TO REINSPECTION AT ANY TIME AT EHD'S CURRENT I•IOURL RATE. <br /> EHD inspector.r Receive �die: <br /> .FID 23- UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11117/106 <br />