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UW N. SAN JOAQUIN COUNTY 40 C. ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 F ` Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siQov.or /q ehd a�/FOR� Facility Name: Inspection Date: ❑ mechanical Model: VkA CD Z400 Facility Address: THIS IFACILT�gLl Service Request #: Onsite ervice Technician's Name: f �UA Leak detector ICC Service Technician/Installer Exp. Date. Manufacturer Training: L ❑ electronic Serial #: ❑ ❑ line test prograrrimed SERVICE jftr- 11 Leak detector ❑ mechanical Model: VkA CD Z400 ❑ electronic Serial #: THIS IFACILT�gLl ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test prograrrimed sensor ❑ ❑ positive shutdown Model: ❑ 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) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other THIS IFACILT�gLl 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 2° 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 ❑ This UST facility is NOT APPROVED to operate tW WEri THIS IFACILT�gLl a-. � t A P I TI -40., I a a ma M1 EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10