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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 /> Facility / }� Facility <br /> Name: �� 3 S o*Vr1 SefV)14 Ce,4er Address: 4040 wesf Lowe <br /> Facility1 <br /> Contact: A ex s+ee.Ie Title: L^,,v,f mcvJcJ Fb'eld 4LIG1tST <br /> Contractor Information - <br /> Contractor ' <br /> Contractor <br /> Name: t ✓I V r�D►�rvIPY�>C4 5 t (eS S _TT ni. Address: 701 /V. er <br /> CA License Contractor <br /> Number: Class:cl0 g A Phone#: 7114 710 0 <br /> ^ Workers' <br /> Insurer: <br /> 4Me�yvl C-,� ot3 jndemn+t3 Coyh Alli Com .#: Oggl.5D .? <br /> ICC Tech: 1:v<,j-ie f VJa rre vi Exp. Date: tobhz <br /> ICC Installer: Exp. Date: <br /> Manufacturer 'w Exp. Date: <br /> Training: eeC)Qr K' � Z-IT , <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> Model: y'ZO 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 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> Y other: www .0 as*" unn 01cu- ❑ 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 /> PR#: PE: SC: 098 Accepted By/ Date: <br /> Assigned To: <br /> EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM <br />