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ENVIRONMt TAL 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 Vo <br /> /) _Q <br /> Facility ^ n -A� %62)IS Address: 5!0 w V oi— ` i c o ck 7 Q <br /> Fac l.ty <br /> Name: W v <br /> Facility <br /> Contact: R 1 Title: <br /> Contractor Information <br /> Contractor 1, 'I ContractorI �y <br /> Name: —�!�\� e�— Address: '�( <br /> CA License p Class: Contractor SO0 _ ^ej y <br /> Number: "1 S D �� Phone#: <br /> //^�^� Workers' ry u/ <br /> Insurer: I'OQ,ti I a brs W - Comp.#: rj C! y (b "( L4 <br /> ICC Tech: Alikzl Exp. Date: (v S —?JC)_2,0 1 S <br /> I <br /> ICC Installer. br� Exp. Date: V S �30 _ 2Q cJ <br /> Manufacturer Exp. Date: <br /> Trainin �/1 Z C) �L — :� a'1�"�5 V� 2- t,3 —) <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement �nv\?_ Se "or) ElSensor replacement <br /> Model: rlg4. OSA"hl 103 311 g Model. <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> X91 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: ❑ other: <br /> Leak detector re lacement El Leak detector replacement <br /> Model: Y� t (0 Model: <br /> )(87-octane ❑ -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) q— El Spill container replacement(not direct bury) <br /> Model: Ct�kOL r�joiQ CP vyl QX,IJ( Model: <br /> ❑ 87-octane T ❑ 89-o tane UST ❑ 87-octane UST ❑ 89-octane UST <br /> x(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 /> By <br /> PR#: 0 5 � PE: SC: 098 Ass gnted ed To/ Date: O_�Q_� <br /> EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM <br />