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W.O.# NW1-232989-' <br />;,/ <br />ENVIRONMENTAL HEALTH DEPARTMENT a s zoic <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />DEPARTMENT <br />UNDERGROUND STORAGE TANK <br />RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br />Facility Information <br />Facility Facility <br />Name: YRS =AIC. Address: 1535 E. PE5,{ApER0 AVc .TRACY <br />Facility Title: <br />Conlacr KRIS 6LAWKIC Stilt MANAGE o° <br />Indicate below type of work to be performed. Check all that apply. <br />CY Sensor replacement ❑ Sensor replacement <br />Model: '7943 $o - z08 Veelioi Roo(- Model: <br />❑ 87 piping sump <br />Contractor <br />lnforrnatldn <br />D 89 fill sump <br />❑ 91 piping sump <br />Contractor <br />❑ diesel piping sump <br />Contractor <br />_ <br />a <br />Name: <br />G <br />Address: <br />!t)a �- <br />USt W J < 6 LJ t <br />CA License <br />Number: I <br />❑ Leak detector replacement <br />Class: <br />Z <br />Contractor <br />Phone #: <br />6'9-� 3 <br />_ <br />- 12 <br />- 91 -octane UST <br />❑ diesel UST <br />= other <br />Insurer:Workers' <br />Model: <br />Comp. #: <br />WcA iq <br />Zo Ste{ <br />ICC Tech <br />9 <br />Exp. Date: <br />3 <br />ICC Installer: <br />Model: <br />Exp. Date: <br />= 87 -octane UST <br />c 89 -octane UST <br />Manufacturer <br />c diesel UST <br />Exp. Date: <br />171 <br />Tminin <br />7 1 <br />18 <br />Indicate below type of work to be performed. Check all that apply. <br />CY Sensor replacement ❑ Sensor replacement <br />Model: '7943 $o - z08 Veelioi Roo(- Model: <br />❑ 87 piping sump <br />c 87 fill sump <br />❑ 89 piping sump <br />D 89 fill sump <br />❑ 91 piping sump <br />c 91 fill sump <br />❑ diesel piping sump <br />c diesel fill sump <br />e dispenser 1/2 <br />c dispenser 3/4 <br />c dispenser 5/6 <br />c dispenser 7/8 <br />c other: (/5a 6,11 (TA <br />0 2 <br />ip v�,ag <br />5u m—�tl`1 <br />❑ Leak detector replacement <br />Model: <br />- 87 -octane UST <br />a 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 � 89 -octane UST <br />c 91 -octane UST = diesel UST <br />c other <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />c 87 piping sump <br />c 87 fill sump <br />c 89 piping sump <br />c 89 fill sump <br />c 91 piping sump <br />c 91 fill sump <br />c diesel piping sump <br />- diesel fill sump <br />dispenser 1/2 <br />c dispenser 3/4 <br />c dispenser 5/6 <br />c dispenser 7/8 <br />- other: <br />L O 0 0�9 t1 axr3 <br />❑ Leak detector replacement <br />Model: <br />z 87 -octane UST <br />a 89 -octane UST <br />= 91 octane UST <br />a diesel UST <br />c other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />c 87 -octane UST <br />c 89 -octane UST <br />❑ 91 octane UST <br />c diesel UST <br />c other: <br />0 Automatic tank gauge (ATG) replacement <br />Model: <br />= 87 -octane UST <br />c 89 -octane UST <br />= 91 -octane UST <br />c diesel UST <br />c other: <br />'This applies only if contractor has all required certifications. <br />[PIR' 2 J I PE: K 3 6 I I Sc: 098 I Assignted To/ ) '00" — 1 Date: 1 <br />