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ENVIRONM TAL HEALTH DE ARTMENT <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 /> 4`"tea;:; € - <br /> # M= -_ Facility>Information :. :`. - <br /> Facility 1 Facility --7 <br /> Name: t l` � Address: /�i^]Z o <br /> Facility 1 Title: <br /> Contact: r,h+, � <br /> "W�Contractor]nforrnationRE <br /> Contractor f Contractor <br /> Name: r✓1rer4Address: V- �, � ( S <br /> CA License —1 Class: /� 11 Contractor <br /> Number: ! /'• r7 Phone#: <br /> Workers' <br /> Insurer: f� Com .#: 22 (7� <br /> ICC Tech:--Sc3S� ^ ^ _ Exp. Date: <br /> ICC Installer: Exp. Date: <br /> Manufacturer +.t 1� y Exp. Date: <br /> Training: T� <br /> Indicate below type of work to be performed. Check all that apply. <br /> C] Sensor replacement ❑ Sensor replacement <br /> Model: 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 ❑ 91 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: ❑ other: <br /> ❑ Leak detector replacement ❑ 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) XSpill container replacement(not direct bury) <br /> Model: Model ©PV,) I-Z t dC2 U LG w"Fe' <br /> ❑ 87-octane UST ❑ 89-octane US: ❑ 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: o.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/ Date: <br /> PR#: �.2 (� PE: I SC: �9$ Assigned <br /> EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM <br />