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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 AA^^ Facility C p� + , <br /> Name: �� Iv` Address: J5V �A11 1 L0 ZC) • <br /> Facility Title: <br /> Contact: 1��. \G� er <br /> Contractor Information <br /> Contractor Contractor I <br /> Name: Y—C,, ,j Address: <br /> CA LicenseC Class: Contractor <br /> Number: J s� 5, Phone#: — <br /> ( Workers' <br /> Insurer: �� C nkGtorS n c. Comp.#: <br /> ICC Tech: � Exp.Date: <br /> ICC Installer: Exp.Date: <br /> Manufacturer .` I p Exp.Date: Z <br /> Training: v E� ` <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> ❑ 87 piping sump n 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑89 fill sump <br /> o 91 piping sump ❑ 91 fill sump ❑ 91 piping sump o 91 fill sump <br /> ❑ diesel piping sump ❑ diesel fill sump o diesel piping sump ❑diesel fill sump <br /> ❑dispenser 1/2 o 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 /> o 87-octane UST o 89-octane UST o 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST o diesel UST o 91-octane UST o diesel UST <br /> ❑other: a other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> ❑87-octane UST o 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> 0 91-octane UST ❑ diesel UST ❑ 91-octane UST o diesel UST <br /> 0 other: ❑ other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: o 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 /> C)5 x ' : SC: 098 Accepted By/ Date: <br /> PR#: ��•, PE <br /> V J J S :2 Assigned To: <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT V RIFIC ION FORM <br />