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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 /> Facil Information <br /> mcJ I A -P4/ Z2cility <br /> ot0ly Address: 2 ! <br /> Facility Title: ' <br /> Contact: <br /> Contractor Information <br /> Contractor Contractor <br /> Name: 6& I S t@ VYI 3 Address: �"'�•' <br /> CA LicensetZ '`I� CoL- <br /> ntractor _ <br /> Number. (/s ��: y C L l D Phone a: <br /> Insurer. �nSVrLdn b t� a ComWorke# K� P L 2 1 , 0 7 0 <br /> ICC Tech: f I-54-6 )1 SDC 1 Exp.Date: <br /> ICC Installer: S jj-3 Exp.Date: <br /> Manufacturer Exp.Date: <br /> Traini <br /> Indicate below type of work to be performed. Check all that apply. <br /> , <br /> ®'Sensor replacem�j�,M 'I o il(, 04 ?b 5aq � El Sensor replacement <br /> Model: /R'7 c O O ` pg t)a V Model: <br /> ❑ 87 piping sump ❑87 fill sump 6-%0e ❑ 87 piping sump ❑87 fill sump <br /> x 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑89 fill sump <br /> ❑ 91 piping sump 1191 fill sump ❑ 91 piping sump 1191 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 /> Accepted <br /> p d i3 G G q PE 13L1 sc 098 A:e To Da[ <br /> EHD 2395 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />