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h <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 'Y I Facility <br /> Name: 'y ` o,'�� 3 Address: 1 '1 <br /> Facility Title: <br /> Contact: r <br /> Contractor Information <br /> Contractor Contractor v <br /> Name: ! Address: r 'te( 4 <br /> License Class: Q Contractor <br /> Nu <br /> Number: I , Phone#: <br /> Insurer: ` Workers' <br /> L <br /> Comp.#: <br /> ICC Tech: V <br /> Exp. Date: <br /> ICC Installer: Exp. Date: <br /> Manufacturer L4Exp. Date: 3I�• �1 <br /> Training: KA0j- <br /> Indicate b ovtype of work to be performed. Check all that apply. <br /> Sensor replacement Sensor re la ement SN �- <br /> Model. V .6 � 20qI Model <br /> ❑ 87 piping sump ❑ 87 fill sump )4,87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump o 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 o dispenser 3/4 <br /> ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> F10 �i �(.� �� ❑ 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 /> ❑ 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 /> *This applies only if contractor has all required certifications. <br /> PR#: V cjb PE: ?�s 1 SC: U98 Accepted Assigned To/ Y1 Date: `L�+ �� <br /> EHD 23-05 Rev.07116/12 UST RETROFIT VERIFICATION FORM <br />