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0 <br /> 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 'TW ,►7 Facility 0 <br /> Name: / Address: L V A r A <br /> Facility ,Dt' , r Title: <br /> Contact: r (�.j� f <br /> Contractor Information <br /> Contractor Contractor <br /> Name: E11-fie Address: <br /> CA License % © j •2 Class: Contractor +� 7 <br /> Number: Phone#: <br /> Insurer: { } !1� %T' workers' /, <br /> �' +YC / '0' Com .#: 0133392 <br /> ICC Tech: Ly Exp.Date: G <br /> ICC Installer: JCS % hi `' Exp.Date: L? 1f <br /> FManacturer `/ Exp.Date: <br /> : L - ;� a 0-i- <br /> Indicate <br /> Z <br /> Indicate below type of work to be performed. Check allthatapply. <br /> Sensor replacement tS Y+ ❑ Sensor replacement <br /> Model: — 4 2, 0 15 L Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump n 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 /> ❑other: E' 4 1l,i ( ��1Gf 'y ❑ 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 /> u 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 /> OkL t Jv <br /> 'This applies only if contractor has all required certifications. <br /> f 1 r2 iJ �G}.N' U�ryl J d 7 <br /> PR#: n PE: sC: 098 Accepted By/ _7Date: r <br /> V� 3 � -1 3G Assigned To: J �� <br /> EHD 23-05 Rev 07/20/12 UST RETROFIT VE7RIFICATION FORM <br />