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ENVIRONMENTAL HEALTH D •ARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* r k.a' x�_ 4__Facili-lrformation, .. 8: a Facility ❑ 89 piping sump ❑ 89 fill sump Facility Name: } 1 ' _- `fT//✓`SAnL., W Address: Facility �A „/) ; �`"r`�� Title: � Contact: Address: US RETROFIT VERIFICATION FORM Indicate below type of work to be performed. Check all that apply. Y Sensor re laceme�ntt%Model: � r' � ><87 piping sump r _ sContractorinformation, ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump Contractor, } 1 ' _- `fT//✓`SAnL., Contractor ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 Name: ❑ other: Address: US RETROFIT VERIFICATION FORM CA License Number: I fid b j i5 Class: r p j A � i C Contractor Phone #: a 10 Insurer: Workers' Comp. #: V �� ICC Tech: Exp. Date: 3 11 20 / (a �S 0 /s - ICC Installer: Exp. Date: Manufacturer Exp. Date: Trainin : Indicate below type of work to be performed. Check all that apply. Y Sensor re laceme�ntt%Model: � r' � ><87 piping sump 1187 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: Dispenser: Grade: Dispenser: Grade: Dispenser: Grade: *This applies only if contractor has all required certifications. �1 Sensor replacp9je Model �J� �---�q3- G'�l7 ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other' 6Assigned PR#: �j `` � PE: ��g SC: 098 Accepted By/ To:�(' %�)- I ( �n � /v"' Date: q l all 1��,4 EHD 23-05 Rev. 07/16/12 US RETROFIT VERIFICATION FORM