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ENVIRONA TAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Name: J�J �/1 kJ �j Facility (55 Address: Facility ' Contractor++ Name: Title: f �- Contact: ❑ dispenser 1/2 Contractor Address: Indicate below type of work to be performed. Check all that apply. Sensor replacement _VI_ Q__T Model: 0-4 Qa3ao _ g ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump Contractor Information ❑ 91 piping sump Contractor++ Name: � LA � ® ❑ dispenser 1/2 Contractor Address: C � � Q. CA License Number: / _] Q V —f (� ❑ other: Class: f� t-� �� Contractor Phone #: 7:p Insurer: h (,Q ��Ak Workers' Comp. #: A !� V / 4- I V ICC Tech: QD VA yjaoc) Exp. Date: -- —a ICC Installer:PAO ) I am1L . Date: "b '" 3-2-o ,o Manufacturer,� Training: V �,, ( al/� Exp. Date: 1 Indicate below type of work to be performed. Check all that apply. Sensor replacement _VI_ Q__T Model: 0-4 Qa3ao _ g ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 other: �Sb'F-► ❑ other: 6e r 2 (inna;� ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ 91 fill sump ❑ Spill container replacement (not direct bury) Model: ❑ dispenser 1/2 ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model:�� ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Dispenser: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: Grade: Dispenser: Grade: Dispenser: Grade: Dispenser: Grade: *This applies only if contractor has all required certifications.