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ENVIRONMEATAL HEALTH DEARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE ME Fac►It. Infarmat4on .,. - , R,x� FacilityFacility Roo � V� � '" � y Name: t C Address: Facility Title: v con Contact: Class: dc. n a, n € Co tra orinforrhation Contractor ® +Contractor Name: R- p �- P � ) Address: 11 �(� S CA License .�g Number: �t ❑ dispenser 1/2 Class: Contractor Phone #: _ 5g G Insurer: C ` S `c@ I ComWorkp. #: Q04.; ICC Tech: Exp. Date: L4 _2- _ i% ICC Installer: Exp. Date: ' — Manufacturer Exp. Date: - -®' Training:'� Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement Model: ❑ 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: eak detector replacement Model: D l ❑ 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 ❑ Sensor replacement \ISs- ❑ 87 piping sump ❑ 89 piping sump ❑ 91 piping sump ❑ diesel piping sump ❑ dispenser 1/2 ❑ dispenser 5/6 ❑ other: ❑ 87 fill sump ❑ 89 fill sump ❑ 91 fill sump ❑ diesel fill sump ❑ dispenser 3/4 ❑ dispenser 7/8 ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 91 -octane UST ❑ other: ❑ 89 -octane UST ❑ diesel UST ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Dispenser: Grade: Model: Dispenser: Grade: ❑ 87 -octane UST ❑ 89 -octane UST Dispenser: Grade: ❑ 91 -octane UST ❑ diesel UST Dispenser: Grade: ❑ other: "This applies only if contractor has all required certifications.