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ENVIRONM• TAL 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 />-"Facili =Information <br />Facility <br />Name. IJ('� <br />Facility D _ <br />Address: _ f E 5 L ER Ayr Y <br />Facility <br />Contact KRIS S i P <br />Title: <br />Indicate below type of work to be performed. Check all that apply. <br />® Sensor replacement ❑ Sensor replacement <br />Model: X9436o - 208 Veeliaw Roof Model: <br />❑ 87 piping sump <br />kCuotncfoYJiifnmtab <br />Q.. <br />D 89 fill sump <br />Contractor <br />G <br />Contractor <br />Ida 1 J <br />Vv'li B Lotti <br />Name. <br />N <br />Address: <br />YtPUS1 - 5v. < <br />CA License <br />Number: <br />16o <br />Class: A <br />Ay, Z_ <br />Contractor <br />Phone #: <br />_ <br />.2 d q --� 3 ^ 1 2 <br />Insurer: <br />S L V 5 <br />Workers' <br />Comp. #: <br />WC A iq la 5--4S 16 <br />ICC Tech: <br />51Exp. <br />Date: <br />.3 1 IX <br />ICC Installer: <br />❑ Spill container replacement (not direct bury) <br />Exp. Date: <br />Manufacturer <br />❑ 89 -octane UST <br />Exp. Date:7171 <br />❑ diesel UST <br />Training: <br />18 <br />Indicate below type of work to be performed. Check all that apply. <br />® Sensor replacement ❑ Sensor replacement <br />Model: X9436o - 208 Veeliaw Roof Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />D 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑other: USed 0,1 (TA6249 <br />504 ) <br />Pi I )ta <br />5 u v." yVas+rr , i <br />❑ Leak detector replacement <br />Model: <br />Model: <br />❑ 87 -octane UST <br />❑ 91 -octane UST <br />❑ other: <br />❑ 89 -octane UST <br />❑ diesel UST <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />D 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />Lb0oto 11a"s <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />0 other: <br />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />D other: <br />'This applies only if contractor has all required certifications. <br />PR#:.PE:3LISC: X98Accepted Date: ZqJ Assigned To: <br />EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM <br />