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ENVIRONMENTAL 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 fy. Facility ' Name: Address: Facility Title: Grade: _ Contact: Name: ❑ dispenser 516 Indicate below type of work to be performed. Check all that apply. Sensor replacement <!4, ;t-�--- S 0� Model: VF- ;Z ;2 ---s j� ❑ 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 112 ❑ dispenser 314 ❑ dispenser 5f6 f ❑ dispenser 718 'other: qI ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane US1 ❑ 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-. ❑ Bravo float and chain replacement Dispenser: Contractor Information Dispenser: Grade: _ Contractor Grade-. _ contractor Grade: _ j�jo Name: ❑ dispenser 516 Address: ❑ other: [_ V CA License Class: Contractor ❑ 87 -octane UST Number: ❑ 91 -octane UST Phone #: ❑ other: ❑ Spill container replacement (not direct bury) Co Workers' ❑ 87 -octane UST ❑ 89 -octane UST Insurer: 1 Comp, �c rpt Automatic tank ga e (ATG) replacement 4. (Odt ICC Tech: A14pZsm Exp. Date: 06224 ICC Installer.Exp. Date: Manufacturer Exp, Date: Trainin : Indicate below type of work to be performed. Check all that apply. Sensor replacement <!4, ;t-�--- S 0� Model: VF- ;Z ;2 ---s j� ❑ 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 112 ❑ dispenser 314 ❑ dispenser 5f6 f ❑ dispenser 718 'other: qI ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane US1 ❑ 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-. ❑ Bravo float and chain replacement Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade-. _ Dispenser: Grade: _ *This applies only if contractor has all required certifications. ❑ 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 112 ❑ dispenser 314 ❑ dispenser 516 ❑ dispenser 718 ❑ 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: �c rpt Automatic tank ga e (ATG) replacement 4. (Odt Model. (� 9 X87 -octane UST A ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: OZism & bulb PE. SC: a$ Accepted By! PR#: Q ar?fr7�l 2,3C,1 Assigned To: 0711 Date: D &9_i 1 __1 rROFIT VERIFICAT3ON F,