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OP''4u I N•.0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT y. 600 East Main Street, Stockton, CA 95202-3029 i Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd 09�iFOw�/ UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: LL -C, Inspection Date: —201 Facility Address: t --�) ca "VIsJ� � �/ Service Request #: 016 Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufa ur r ng--71217,[2- YZ ❑ line test programmed 01Z 01Z — SERVICE i WEAM Leak detector ❑ ❑ mechanical Model: - - ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed jes�N_- sensor GkYIYIUW,r. ❑ Model: VQ1 * q` 2KO —W positive shutdown ❑ fail safe Serial #: ❑ ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) 91 SERVICE i WEAM Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS - - ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after. and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below � rPALM 111=70=10 W4111 i WEAM - - EHD_1spector,-.: � W�.AWJWWWJ� EHD 23-04 Rev 11/17//08 Nb v�� r r r'i � �/ � � k feCfT SENA ERE I ES1tIN60elOtNREPORT �M� "rS 4u --e RIC)M �2Z Ll .