Laserfiche WebLink
11 <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420. Fax: (209) 468-3433 SEP 0 <br />UNDERGROUND STORAGE TANK <br />RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSI7 *'-C <br />Faclllty Info miafidn 7777777:' <br />FacilityFacility <br />6+b'o <br />Law <br />Name. ;X <br />Address: -9, <br />Facility <br />sdl�) <br />Title: <br />Contact <br />E3 dispenser 1/2 <br />Indicate below toe of work to be performed. Check all that apply. <br />0 Sensor replacement <br />Model: <br />n 87 piping sump <br />o 87 fill sump <br />0 89 piping sump <br />El 89 fill SUMP <br />a 91 piping sump <br />0 91111 sump <br />o diesel piping sump <br />o diesel fill sump <br />E3 dispenser 1/2 <br />o dispenser 314 <br />• dispenser 5/6 <br />n dispenser 7/8 <br />• other., <br />U Leak detector replacement <br />Model: <br />* 87 -octane UST o 89 -octane UST <br />* 91 -octane UST o diesel UST <br />* other: <br />0 Sensor replacement <br />Model: <br />* 87 piping sump <br />a 87 fill sump <br />* 89 piping sump <br />1189 fill sump <br />* 91 piping sump <br />13 91 fill SUMP <br />* diesel piping sump <br />E3 diesel fill sump <br />* dispenser 112 <br />E3 dispenser 3/4 <br />* dispenser 516 <br />o dispenser 7/8 <br />in other <br />0 Leak detector replacement <br />Model: <br />a 87 -octane UST 13 89 -octane UST <br />n 91 -octane UST o diesel UST <br />o other. <br />Spill container placement (not direct bunA 0 Spill container replacement (not direct bury) <br />Model: 174 C _ t V RD W ( <br />0 pk)) Model: <br />a 87 -octane UST a 89 -octane UST o 87 -octane UST n 89 -octane UST <br />)(91 -octane UST o diesel UST E3 91 -octane UST o diesel UST <br />o other: o other. <br />0 Bravo float and chain replacement El Automatic tank gauge (ATG) replacement <br />Dispenser: Grade: Model: <br />Dispenser: Grade: o 87 -octane UST n 89 -octane UST <br />Dispenser. Grade: Ei 91 -octane UST n diesel UST <br />Dispenser: Grade: u other. <br />*This applies only if contractor has all required certifications. <br />Assigned To:'\U_d__ Date: <br />PR*. PE: Accepted By/ <br />