COMPLIANCE INFO_2010-2015 - Laserfiche WebLink

Home Browse Search

-0 ENVIRONMPNTAL HEALTH DEPARTMENT 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUNDSTORAGETANK Indicate below type of work to/e performed. Check all that apply. U Sensor replacement Model: ❑ Sensor replacement Model: Facilit A 0 !-A C. Facility (. Name: /� / t/li P. FC��CC Address: ❑ 91 fill sump Facility t. fi ❑ diesel piping sump ❑ diesel fill sump Address: �° [ �� Title: 5�zctf +4 Contact: V ` Class: ❑ dispenser 7/8 Contractor ❑ dispenser 7/8 ❑ other: Indicate below type of work to/e performed. Check all that apply. U Sensor replacement Model: ❑ Sensor replacement Model: Contractor( ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump (. Contractor /� / t/li P. FC��CC 1 Name: ❑ 91 fill sump "t fllf� t. fi ❑ diesel piping sump ❑ diesel fill sump Address: �° [ �� A� CA License ❑ dispenser 1/2 ❑ dispenser 3/4 Class: ❑ dispenser 7/8 Contractor ❑ dispenser 7/8 ❑ other: Number: ( r Phone #: Leak detector ElLeak detector replacement Insurer: �✓ : @ ` Comers' 6 ❑ 87 -octane UST ICC Tech: o kAYk_eAJz;jk ❑ 91 -octane UST ❑ diesel UST Exp. Date: - .2-0 1 A57 ICC Installer: ❑ Spill container replacement (not direct bury) ❑ Spill container replacement (not direct bury) Exp. Date: Model: Manufacturer ❑ 87 -octane UST '9 3 w- ❑ 87 -octane UST Exp. Date: � 0 / ❑ 91 -octane UST Training: ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain Indicate below type of work to/e performed. Check all that apply. U Sensor replacement Model: ❑ Sensor replacement Model: 7 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump 1:191 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ other: Leak detector ElLeak detector replacement Ilacement Model Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST 91 -octane UST ❑ diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Spill container replacement (not direct bury) ❑ Spill container replacement (not direct bury) Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain replacement ❑ 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. r PR#: 02,31 PE: �^g 1 sC: 098 Accepted By/ Date: L� 014 L� Assigned To: EHD 23-05 Rev. 07/16/12 U RETROFIT V RIFICA ION FORM