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0 <br />ENVIRONMENTAL HEALTH DE#ARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />u <br />Facile, <br />Con racfor-t <br />Facility� ,�f �{ , <br />Name: ! �j(2 v`- tom" 2 <br />Facility <br />Address: MT. 1Y Ma --n e- <br />FacilityTitle: <br />V <br />1r <br />Contact: <br />Contractor <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />TWO - <br />❑ 87 piping sump <br />❑ 89 piping sump <br />❑ 91 piping sump <br />❑ diesel piping sump <br />❑ dispenser 1/2 <br />❑ dispenser 5/6 <br />❑ other: <br />❑ 87 fill sump <br />❑ 89 fill sump <br />❑ 91 fill sump <br />❑ diesel fill sump <br />❑ dispenser 3/4 <br />❑ dispenser 7/8 <br />Leak detector replacement <br />Model: <br />❑ 87 -octane UST- 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Con racfor-t <br />forrnatmn <br />Grade: <br />Contractor <br />_ "� <br />� <br />Dispenser: <br />Contractor <br />paw ���0. Mat r �� <br />Name: <br />1'e . <br />❑ dispenser 7/8 <br />Address: <br />�C� e <br />CA License <br />Number: <br />Model: <br />Class: <br />❑ 87 -octane UST <br />Contractor <br />Phone #: <br />1 / <br />Insurer: AW <br />/� /- <br />orkers' <br />Com . #: <br />�. <br />ICC Tech: <br />❑ 87 -octane UST <br />Exp. Date: <br />/ <br />ICC Installer: <br />❑ other: <br />Exp. Date: <br />replacement <br />Manufacturer— <br />Q <br />❑ 87 -octane UST <br />Exp. Date: <br />❑ 91 -octane UST <br />Training:V/WL <br />❑ other: <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />TWO - <br />❑ 87 piping sump <br />❑ 89 piping sump <br />❑ 91 piping sump <br />❑ diesel piping sump <br />❑ dispenser 1/2 <br />❑ dispenser 5/6 <br />❑ other: <br />❑ 87 fill sump <br />❑ 89 fill sump <br />❑ 91 fill sump <br />❑ diesel fill sump <br />❑ dispenser 3/4 <br />❑ dispenser 7/8 <br />Leak detector replacement <br />Model: <br />❑ 87 -octane UST- 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <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) <br />replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#:6✓d-a1 -F `f Z' PE: sC: 098 I Ass ped By <br />05f yQj--1P6Date: <br />EHD 23-05 Rev, 07/16/12 UST RETROFIT VERIFICATION FORM <br />