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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 />l • • ' — <br />• •' i • <br />.. , iFei Ill , tatt <br />Facility . Facility <br />Name:. ' °'a . Y �. Address: 9-7 Z <br />Fality <br />Contact: TQ o m 00 fzTitle: d" CI 0a aer <br />Contractor g�,�, Contractor Can b� <br />Name: S Ce 1 �� IY�I�C <br />Address: �� <br />AvLo- <br />CA License - ContractorCONumber: I �� lassL Phone #: I 1 -°3 <br />Insurer: f <br />'t Com er#: / <br />ICC Tech: Exp. Date: /2 <br />ICC Installer: Exp. Date: <br />Manufacturer�r / Exp. Date: <br />Training:�1 <br />Indicate below type of work to be performed. Check all that apply. <br />Sensor replacement <br />Vgg C oo <br />Model: 0(84—T <br />f <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 filr sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump ❑ diesel fill sump <br />❑ dispenser 1/2 <br />dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />Model: <br />❑ Leak detector replacement <br />Model: <br />❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />Model: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />Model: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />*This applies only if contractor has all required certifications. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />Accepted By/ Date: 6 <br />PR#: 23 n I `T PE: SC: O98 Assigned To: <br />EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM <br />