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ENVIRONMENTAL HEALTH DErARTMENT <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 1. - - <br /> Facility 'j-+� ,. ,-r' Facility 'A,. <br /> Name: "fi'l'l (�-7� Address: vv <br /> Facility <br /> Contact: 1 111 (lel Title: �Q�� <br /> Contractor ,^��^, aeContractor p I 1 �j/� <br /> Name: 1[.l G Address: r -O O\,]` 4 of V <br /> CA License1-� Class: Contractor <br /> Zo <br /> Number: J n Phone#: <br /> Insurer: r� Workers' ^ Lra�3y� <br /> ICC Tech: Chad Wk1ae Exp. Date: ,043 r <br /> ICC Installer: ` _e_ Exp.Date: 0 .� <br /> Manufacturer \_ � Exp.Date: VK : R a - ! { Q Ib <br /> Trainin : f,' <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement / ❑ Sensor replacement <br /> Model: 30q4 1044LA 5 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 /> ❑ dispens r5/6 ❑ dispenser 7/8 11 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> other: V p ❑ other: <br /> Spy f <br /> ❑ Leak detector re lacement ❑ 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 /> 0 other: ❑ other: <br /> CU r <br /> Spill container r¢ (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 /> 4,91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> `g{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: A SC: Accepted By/ <br /> 015 Date: n <br /> V 0300 098 Assigned To: <br /> EHD 23-05 Rev.07 2 UST RETROFIT VERIFICATION FORM <br />