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ENVIRONMLNTAL HEALTH DEMA'RTMENT <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 _ , <br />Facility <br />Name: % �G'L�ll <br />Address: <br />Facility c <br />Contact: 7 �V1. <br />Title: <br />►' �— <br />Indicate below type of work to be performed. Check all that apply. C oO� 0,r+ .5(c) U_ � <br />�'VR- i_Cpu 6CCLrd vvwrZptoLee.d t° 353403 �hj, f �f'-�` <br />El Sensor replacement <br />Contractor Information <br />C4 vYl fbNa4 <br />�k0VLV <br />Contractor� <br />Name: <br />Model: <br />Contractor <br />Address: <br />102 -TT .ACWAY•Al <br />Uaa(- <br />CA License/� <br />Number: "()I <br />❑ 87 piping sump <br />Class: <br />❑ 89 piping sump <br />Contractor <br />Phone#: <br />r� <br />Insurer: <br />' <br />❑ 91 piping sump <br />Workers' <br />Comp. #: <br />QteQ� .V vickc WCA ")�t)5 &lZ <br />ICC Tech: <br />r -go War' rejti <br />❑ diesel fill sump <br />Exp. Date: <br />I <br />ICC Installer: <br />❑ dispenser 3/4 <br />❑ dispenser 1/2 <br />Exp. Date: <br />❑ dispenser 5/6 <br />Manufacturern� <br />Training:i <br />Q cb woa� <br />❑ dispenser 7/8 <br />Exp. Date:14 <br />9 — 4Q 6 — <br />Indicate below type of work to be performed. Check all that apply. C oO� 0,r+ .5(c) U_ � <br />�'VR- i_Cpu 6CCLrd vvwrZptoLee.d t° 353403 �hj, f �f'-�` <br />El Sensor replacement <br />❑ Sensor replacement <br />C4 vYl fbNa4 <br />�k0VLV <br />Model: <br />Model: <br />G�t-1 t . <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 87 piping sump <br />❑ 87 fill sumps <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ other: <br />❑ Leak detector replacement <br />❑ Leak detector replacement <br />Model: <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />❑ Spill container replacement (not direct bury) <br />Model: <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Bravo float and chain replacement <br />❑ Automatic tank gauge (ATG) <br />replacement <br />Dispenser: <br />Grade: <br />Model: <br />Dispenser: <br />Grade: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />Dispenser: <br />Grade: <br />❑ 91 -octane UST <br />❑ diesel UST <br />Dispenser: <br />Grade: <br />❑ other: <br />*This applies only if contractor has all required certifications. — �J" w Qfr\c, ('jp4Jlr' ��C� ; 10 - S -13 <br />