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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK <br />RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br />_- <br />Facility Information <br />Facilityc <br />Name: ( n 1 <br />Facility <br />Address: <br />Facility <br />Title: <br />Contact: <br />1 <br />I V V -j <br />Indicate below type of work to be performed. Check all that apply. <br />Sensor replacement <br />— <br />Contractor Information <br />Model: 33 Ob 0 9 <br />Contractor .T <br />❑ 87 piping sump <br />Contractor <br />1 <br />Name: <br />❑ 91 piping sump <br />Address: <br />{ Cl <br />CA License <br />Number: _1 4 s t � <br />Class: <br />Contractor <br />Phone #: <br />, w <br />D9 CLQ 14 <br />Insurer: t Ui e <br />(`,op. <br />WorkeRpL�p. rs <br />A q ) O'S Li — <br />ICC Tech::ynCV-06 <br />zz <br />Exp. Date: <br />—do — <br />❑ other: <br />C Installer: <br />rM <br />Exp. Date: <br />anufacturer n <br />Exp. Date: <br />ainin <br />Indicate below type of work to be performed. Check all that apply. <br />Sensor replacement <br />— <br />n <br />6S ��� �j� 1 t <br />Model: 33 Ob 0 9 <br />1'�-� <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispener 5/6 <br />V�,-A11 <br />❑ dispenser 7/8 <br />UnC_ <br />,Kother:63l <br />Model: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 91 -octane UST <br />❑ other: <br />❑ 89 -octane UST <br />❑ diesel UST <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Sensor replacement <br />LAI)`, Model: A�00�D <br />\ <br />_L4 �'i l � t ocx 1 <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />other: ('56) V Q. <br />❑ dispenser 7/8 <br />!i — Ven* -i;\, <br />*This applies only if contractor has all required certifications. <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge <br />(ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />Accepted <br />PR#: cx�—>a (D� I a PE: a;w SC: 09$ Assigned To/ Date: 3 <br />EHD 23-05 Rev. 07/16/12 UST RETROFIT VERIFICATION FORM <br />;TX <br />