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0 0 <br /> 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 /> UNDERGROUND STORAGE TANK <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br /> aril i`, ,orinatissrt4-5 <br /> ,} <br /> Facility Facility <br /> Name: Address: <br /> Facility _ Title: <br /> Contact �/ <br /> Ccntta.. r[ttfurma#ivn' <br /> t = <br /> Contractor Contractor Q /y <br /> Name: ( Address: "l <br /> CA License Class: Contractor <br /> Number: Phone#: <br /> Insurer: orkers, <br /> om .#: <br /> ICC Tech: xp.Date: <br /> ICC Installer: J Exp.Date: <br /> Manufacturer Exp.Date: <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> 0 87 piping sump o 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump 1189 fill sump o 89 piping sump o 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump o 91 piping sump ❑ 91 fill sump <br /> ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump o diesel fill sump <br /> ❑ dispenser 1/2 ❑ dispenser 3/4 o dispenser 1/2 ❑dispenser 3/4 <br /> ❑ dispenser 5/6 ❑ dispenser 7/8 o dispenser 5/6 ❑ dispenser 7/8 <br /> ❑ other: o other: <br /> Leak detector replacement ❑ Leak detector replacement <br /> Model: �AA[ J, Lo '600 Model: <br /> '87-octane UST ❑ 89-octane UST o 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST o diesel UST ❑ 91-octane UST ❑ diesel UST <br /> 0 other: 4,p4g �(�I ��Z ❑ 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 o 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: o 87-octane UST ❑89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST ❑diesel UST <br /> Dispenser: Grade: o other: <br /> *This applies only <br /> iif�contractor has all required certifications.Accepp,� <br /> PR#: 0213 I' �U PE: �, SC: 09$ Assignted By/ <br /> Date: <br /> EHD 23-0V05 Rev.07/20/12 l UST RETROFIT VERIFICATION FORM <br />