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ENVIRONME TAL EALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton, Stockton, CA 95206-6232 <br /> Telephone: (208) 468-3420 Fax; (209) 468-3433 <br /> UNDERGROUND STORAGE TANK <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br /> � <br /> Fsaltity Fasil <br /> FecAftAtkIreoc W- Lai <br /> `' ' A ,- Title: <br /> Cortradar a Qontre or <br /> Addreaa. <br /> C nsecissa: fontraator <br /> t <br /> Numb 464"If Phpne#: <br /> ineurer .. °trflr ►^ 1t11 ; t�5, �y— :. . <br /> lRC <br /> Tech: r.l, °. � t E)0,Date: ' <br /> ICC instalier. Exp, Date: <br /> Tra f 1t ) e �� ,ft Exp_DOW <br /> ____ __ m__ ____.. <br /> Indicate below type of work to be performed. Check all that apply, y A r�� /`� 9 <br /> ^ f_4 1";. pr <br /> Sensor replacement ❑ Sensor replacement �,�� �1 <br /> Modal: Model: <br /> n 87 piping sump 87 fill sump ra 87 plping sump ra B7 fill sump <br /> ❑Be piping sump ❑ 89 flit sump n 89 plping sump r. 89 fill sump <br /> ra 91 piping sump ❑91 fill sump is 91 piping sump o 91 fill sump <br /> ti-diesel piping-sump crdlesei Fill sump n dlese 1ping sump erdiesel fl-suoP <br /> ­ ----• - <br /> a dispenser 112 ra dispenser 314 r;dispenser 1/2 a dispenser 314 <br /> ❑dispenser 518 ❑dispenser 718 ❑dispenser SB u dispenser 718 <br /> bother- %`i cO • i.tdie_ ;) 3t ❑other: <br /> El /Leak detector replacement ❑ Leak detector replacement <br /> Model: Madel: <br /> a 87-octane UST r T n 89-octane UST n 87-octane UST ❑ 89-octane UST <br /> ©91-octane UST n diesel UST u 91-octene UST ❑diesel UST <br /> ❑other, a other. <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model _ Mode <br /> _ l: <br /> an <br /> a 87-octe UST ❑89�ctane U8T to 87-octane UST ❑88-octane UST <br /> a 91-octane UST In diesel UST r 91-octene UST u diesel UST <br /> a other ❑other: <br /> ❑ Bravo float and chain replacement © Automatic tank gauge(ATG)replacement <br /> Dispenser: Gude: Model: <br /> Dispenser Grads: ❑87-octane UST ❑89-octane UST <br /> Dispenser. Grade: _ ❑91-actane UST ❑diesel UST <br /> Dispenser: Grade, µ u other, <br /> 'This applies only if contractor has all required certifications. <br /> PRiOe / i_ PE; Y 5C: <br /> f14 �98 AaaiQn CCWd T7r i ( �, Dater <br /> EHD 23.06 Rsv,o7h&12 t T RETROFIT VERIFICATION FOR <br />