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ENVIRONATAL 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 /> "' �' `Facilit Information " <br /> Facility /+ <br /> Name: Facility l' <br /> Facility Address: 140 0 E • L4-A ry Rd. <br /> Contact: Sj P„/ Title: <br /> EL Contractor Information . <br /> Contractor / le n� ..A Contractor c' "Jv. <br /> Na License / � e,-n/ rb�S n Address. 'Z S 3 S WIC 1,w Xr',Ve S-)/ej+o, rnr <br /> Contractor — <br /> Number: /00 3 3 Class: A — HA2 Phone#7 .20 4 4G/ - 63-3 7 <br /> Insurer: •I _I .t.. Workers'Comp.#: IBN V w C 0 3 3 92_- <br /> tT 1 <br /> ICC Tech: 6140A <br /> ) Exp.Date: <br /> 12- <br /> ICC Installer: Exp.Date: <br /> Manufacturer `/ <br /> Training: y ,_,_ 180 a Exp.Date: Z /)7 <br /> Indicate below type of work to be performed. Check all that apply. <br /> 19/Sensor replacement ❑ Sensor replacement <br /> Model: o"2 0 2) sP,t ;4A i i �40 s9 Model: <br /> a-87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump <br /> ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump <br /> ❑dispenser 1/2 ❑ dispenser 3/4 ❑dispenser 1/2 ❑ dispenser 3/4 <br /> ❑ dispenser 5/6 ❑dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> ❑ other: ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑ other: ❑ other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑ other: ❑ other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: ❑ 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST ❑ diesel UST <br /> Dispenser: Grade: ❑ other: <br /> *This applies only if contractor has all required certifications. <br /> PE: �3(, SC: U 9 Accepted Assigned To/ <br /> `3-OS Rev.07/20/12 UST RETROFIT VERIFICAT10N FORM <br />