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ENVIRONANTAL HEALTH <br /> DAARTMENT <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 /> `IflfOfnlatlon - so. a. <br /> Facility Facility y�/��,,�� r <br /> Name: �� C, Address: ,�rL�ul% � oL <br /> Facility , Title: <br /> Contact: r, <br /> — ,.." ' contractor Information ,�v�.�`..��.� <br /> Contractor Contractor Q ,�__ 1 ^� L) <br /> Name: i, Address: <br /> LA <br /> CA License Contractor <br /> 7 c- <br /> Number: G'` (p Class: Phone#: <br /> Insurer: 1 1 Workers' <br /> .l EJB . Comp.#: 9 <br /> ICC Tech: N iCk CA GkQ � Exp. Date: -So 1 c> <br /> ICC Installer: CK. W b1ori� Exp. Date: � � Q_ 2 01 !� <br /> Manufacturer ,�� / Exp. Date: '7, — _ Go"',Trainin : 1 V <br /> QN <br /> Indicate below type of work to be performed. Check all that apply. <br /> ,Sensor replacement ❑ Sensor replacement <br /> Model: o a Q O ^ "1 C-9 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 1:191 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. q7` '-C1.Uyvujf_�- �( 9 200- ❑ other: <br /> �a u� CA11 11 <br /> ❑ Leak detector repla ment ❑ 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 /> Accepted By/ <br /> PR#:� � PE: SC: 098 Assigned To: Date: <br /> EHD 23-05 Rev.07/1 112 UST RETROFIT VERIFICATION FORM <br />