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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 /> !7 FacilityInfomration <br /> Facility — � e✓ # / 3 3 4- Facility �(/r PeyYS ✓e <br /> Name; Address: <br /> Facility /1 Title: ,� Y <br /> Contact: rri.. CYAda <br /> �Y <br /> Contractor Information <br /> Contractor Contractor c� Q <br /> Name: Address: Y a JUAe U <br /> CA License l' Class: Contractor n M <br /> Number: 7'7 3 I L q V Phone <br /> Insurer: K AU T=L-V S m e : w c a 19,2 o s !s <br /> ICC Tech: S'-f- 'ohExp.Date: <br /> ICC Installer: W S+ Exp.Date: _3 <br /> Manufacturer f e Exp.Date: _ 7 <br /> Training: r <br /> Indicate below type of work to be performed. Check all that apply. <br /> �I Sensor replacement ❑ Sensor replacement <br /> Model: Onnu -9L�� 12 <br /> 0 Model: <br /> ❑ 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 E3 dispenser 5/6 ❑ dispenser 7/8 <br /> h other: On n cYla ✓ _J I Uf� ❑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 /> 1 <br /> PR#: 3? PE:07.3 G SC: U98 Assgnte�dTyi Date: <br /> EHD 23-05 Rev.07/20/12 J UST RETROFIT VERIFICATION FORM <br />