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ENVIRONMATAL HEALTH DEARTMENT SAN JOA►QUIN 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 Facility11 /�^�-� Facility Name: b i t/ Address. Facility JJ Contact: Title: Indicate below type of work to be performed. Check all that apply. (Sensor replacement ❑ 87 fill sump Contractor Information WAI ICJ J Z Contractor Name: 16& _ ti ❑ 89 piping sump Contractor Address: t� D r ( 3160 (qw�� CA License Number: ZClass: 1 V�i Contractor Phone #: ! �}�y 6 Insurer / ❑ other: ❑ 87 -octane UST ❑ Leak detector replacement r ICC Tech: �+y , fb1 "• ❑ diesel UST Exp. Date: Li ! q �to 1-5- SICC ICCInstaller: ❑ diesel UST ❑ other: Exp, [date: ❑ Spill container replacement (not direct bury) Manufacturer Training:VR [JC1/� r I ❑ 87 -octane UST Exp. Date: / / .! /'A— / _0 is - Indicate below type of work to be performed. Check all that apply. (Sensor replacement ❑ 87 fill sump Model:W!s _ WAI ICJ J Z ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump 91, piping sump 1 fill sump ❑ esel piping sump T❑'diesel fill sump dispenser 112 ❑ dispenser 314 ❑ dispenser 516 ❑ dispenser 718 ❑ other: ❑ 87 -octane UST ❑ Leak detector replacement Model: ❑ diesel UST ❑ 87 -octane UST o 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ 87 -octane UST ❑ Spill container replacement (not direct bury) Model: ❑ diesel UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ Dispenser: Grade.- Dispenser: rade:Dispenser: Grade: _ Dispenser: Grade: *This applies only if contractor has all required certifications. ❑ Sensor replacement Model: ❑ 87 piping sump El ❑ 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 ther: ❑ other.- ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST 91 -octane UST ❑ diesel UST ❑ other: Y -Go bCIV� rd WA V ft.. -Lc Mf 6&00 +- P tqs C � PR#: t, U ;Q% '7_ PE: 23� fj SC: 09$ . Accepted By/ V"� Date: 1 /l ( l L3 T 1 Assigned To: END 23-05 Rev. 07/16/12 { j UST RETROFIT VERIFICAT'IpN FORM