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PR#: PE: SC: 098 Accepted By/ Assigned To: Date: EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Name: Facility Address: Facility Contact: Title: Contractor Information Contractor Name: Contractor Address: CA License Number: Class: Contractor Phone #: Insurer: Workers’ Comp. #: ICC Tech: Exp. Date: ICC Installer: Exp. Date: Manufacturer Training: Exp. Date: Indicate below type of work to be performed. Check all that apply. □ Sensor replacement □ Sensor replacement Model: _____________________________ Model: _____________________________ □ 87 piping sump □ 87 fill sump □ 87 piping sump □ 87 fill sump □ 89 piping sump □ 89 fill sump □ 89 piping sump □ 89 fill sump □ 91 piping sump □ 91 fill sump □ 91 piping sump □ 91 fill sump □ diesel piping sump □ diesel fill sump □ diesel piping sump □ diesel fill sump □ dispenser 1/2 □ dispenser 3/4 □ dispenser 1/2 □ dispenser 3/4 □ dispenser 5/6 □ dispenser 7/8 □ dispenser 5/6 □ dispenser 7/8 □ other: ____________________________ □ other: ____________________________ □ Leak detector replacement □ Leak detector replacement Model: _____________________________ Model: _____________________________ □ 87-octane UST □ 89-octane UST □ 87-octane UST □ 89-octane UST □ 91-octane UST □ diesel UST □ 91-octane UST □ diesel UST □ other: ____________________________ □ other: ____________________________ □ Spill container replacement (not direct bury) □ Spill container replacement (not direct bury) Model: _____________________________ Model: _____________________________ □ 87-octane UST □ 89-octane UST □ 87-octane UST □ 89-octane UST □ 91-octane UST □ diesel UST □ 91-octane UST □ diesel UST □ other: ____________________________ □ other: ____________________________ □ Bravo float and chain replacement □ Automatic tank gauge (ATG) replacement Dispenser: _________ Grade: __________ Model: _____________________________ Dispenser: _________ Grade: __________ □ 87-octane UST □ 89-octane UST Dispenser: _________ Grade: __________ □ 91-octane UST □ diesel UST Dispenser: _________ Grade: __________ □ other: ____________________________ *This applies only if contractor has all required certifications.