Laserfiche WebLink
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 /> Facilityfitt- <br /> Facility <br /> Name: � l C�k.1 Address: <br /> Facility a n �j e Title: <br /> Contact: �L? <br /> Contractor Information <br /> Contractor ��!! � Contractor d C �1 SLI 3 <br /> Name: a�6(/1'1�� Tva i Address: J T toKA <br /> CA Licenseq/ 2 2 O Class: Contractor d/� - / S c q r7 <br /> Number: 14 Phone#: �7 (O J <br /> Workers' <br /> Insurer: <br /> E)<e" Comp.#: <br /> ICC Tech: O / j r' Exp.Date: 9 V4 <br /> / <br /> ICC Installer: Exp.Date: <br /> Manufacturer � /� eY � 62 r6 D •7 <br /> Manufacturer <br /> TraininV Exp.Date: J <br /> Indicate below type of work to be performed. Check all that apply. <br /> DO Sensor replacement ser�k�� ��S���l� ❑ Sensor replacement <br /> Model: �>7$ 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 /> ❑ 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 ❑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 ❑ 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#: O G D (� <br /> PE: � SC: 09$ Accepted Assigned To/ Date: <br /> EHD 23-05 Rev.07/20/12 �,/I` UST RETROFIT VERIFICATION FORM <br />