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NVIRONMPNTAL <br />DE <br />�' <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />%7' 'r. f .1'l <br />7,17 a„ <br />5 <br />Contractor <br />❑ 89 fill sump <br />❑ 91 piping sump <br />Contractor <br />❑ diesel piping sump <br />Name: EEO <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />Address: <br />❑ dispenser 7/8 <br />CA License <br />Class: <br />Contractor ,! B 15' <br />0 <br />Model: <br />Number:qEV9 <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />Phone #: ` <br />❑ diesel UST <br />Insurer: <br />❑ Spill container replacement (not direct bury) <br />Workers' <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />Comp. #: 1,a[4134-0 <br />❑ other: <br />ICC Tech: ` AA <br />r <br />Model: <br />Exp. Date: <br />❑ 87 -octane UST <br />ICC Installer: (l <br />❑ 91 -octane UST <br />❑ diesel UST <br />Exp. Date: -7 l <br />Manufacturer <br />Exp. Date: '�� 2, <br />�7i <br />Training: <br />Indicate below type of work to be performed. Check all that apply. <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 WOO <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />' -octane LIST <br />7AI ❑ d li <br />ST <br />❑ other:s <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) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#: 3 I.t- <br />` <br />( PE: Za / � <br />Jo <br />SC: 098 <br />I AssignAccepted By/ ed To: <br />l <br />Date: —E <br />END 23-05 Rev. 07/16/12 <br />UST RETROFIT VERIFICATION FORM <br />low <br />