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ENVIRONMERITAL 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: -6n Address: `J <br /> Facility Title: <br /> Contact: <br /> Contractor Information <br /> Contractor LContractor A Vol <br /> �_ A <br /> Name: Address: �/(,Ll <br /> CA License Contractor <br /> Number: ` Class: (L;Z Phone#: C5 Ll I 13,:3 0 <br /> Workers' f •+� �o 4 5 <br /> Insurer: ��(� Comp.#: �s+l..r c7 <br /> ICC Tech: Exp.Date: <br /> ICC Installer: Exp.Date: <br /> Manufacturer Exp. Date: V = Idyl ((�- ,Lj WDIP _ _K <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> \►Sensor replacement ❑ Sensor replacement <br /> Model: -�&-1, 2%-4 E7 —00( �.�('TiZ't{Pppl O Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump o 89 piping sump ❑ 89 fill sump <br /> �91 piping sump ❑ 91 fill sump o 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: ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST o 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑ other: ❑ other: <br /> Spill container re lacement(not direct bury) `" El Spill container replacement(not direct bury) <br /> Model: _ V%k.-P — 0 Ij. Model: <br /> ❑ 87-octane UST ❑ -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 /> ivoq 3i PE: � � SC: 098TXssigned <br /> ccpted o: Date: <br /> _1 ,.7 To: <br /> EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM <br />