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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 /> Facility Information <br /> Facilityr, /� pp Facility 1 <br /> Name: MVY(J� �\U1 �-�� AdJ dress: 1^Falit <br /> Contact: \,)1 `3��l�l�l Title: 'MMft <br /> jW <br /> Contractor Information <br /> Contractor ((�� ,,,,�� 4� ���, � ) -}- (' rn Contractor <br /> Name: Qb 1jt(AA'NI(J& US Address: <br /> CA License Class: Contractor /r„�„( �31-3k1a <br /> Number: Phone#: II�WK�ttr� <br /> Insurer: Workers' <br /> Com .#: <br /> ICC Tech: Kaym em Exp.Date: O)I L2 7-019 <br /> ICC Installer: Exp.Date: G <br /> Manufacturer WAX <br /> J,„ yl * of �,� Exp.Date: g/4v(� yPJ1 g`'22.'2016 <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> Model: 0-ICA4 2<17 -Mr Model: <br /> ❑ 87 piping sump o 87 fill sump o 87 piping sump c 87 fill sump <br /> o 89 piping sump 1189 fill sump o 89 piping sump o 89 fill sump <br /> o 91 piping sump o 91 fill sump o 91 piping sump ❑ 91 fill sump <br /> diesel piping sump o diesel fill sump o diesel piping sump o diesel fill sump <br /> o dispenser 1/2 o dispenser 3/4 o dispenser 1/2 ❑dispenser 3/4 <br /> o dispenser 5/6 o dispenser 7/8 ❑ dispenser 5/6 o dispenser 7/8 <br /> 0 other: ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST o 89-octane UST o 87-octane UST o 89-octane UST <br /> ❑ 91-octane UST o diesel UST o 91-octane UST ❑ diesel UST <br /> ❑ other: c other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> Ei 87-octane UST o 89-octane UST o 87-octane UST o 89-octane UST <br /> ❑ 91-octane UST o diesel UST o 91-octane UST o diesel UST <br /> 0 other: o other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: 0 87-octane UST o 89-octane UST <br /> Dispenser: Grade: o 91-octane UST o diesel UST <br /> Dispenser: Grade: o other: <br /> 'This applies only if contractor has all required certifications. <br /> PR#: UZ315�g PE: SC: O98 Assigned / Data: i..�/1Z 7-di Sr <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />