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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 />UNDERGROUNDSTORAGETANK <br />XETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />❑ Sensor replacement <br />Facility Information <br />Model: <br />Model: <br />Facility <br />cc <br />❑ 87 piping sump <br />Facility <br />1y� <br />, 'T� �- <br />Name: <br />V b <br />❑ 91 piping sump <br />Address: <br />L <br />�/ <br />Facility <br />5� <br />% <br />Title: <br />Fr" <br />❑ dispenser 5/6 <br />Contact: <br />�i <br />I ��� �� <br />❑ Leak detector replacement <br />❑ Leak detector replacement <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />❑ Sensor replacement <br />Model: <br />Model: <br />❑ 87 piping sump ❑ 87 fill sump <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump ❑ 89 fill sump <br />❑ 89 piping sump <br />1189 fill sump <br />❑ 91 piping sump ❑ 91 fill sump <br />❑ 91 piping sump <br />1191 fill sump <br />❑ diesel piping sump ❑ diesel fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 ❑ dispenser 3/4 <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 ❑ dispenser 7/8 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ other: <br />❑ Leak detector replacement <br />❑ Leak detector replacement <br />Model: <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />Spill container replacement (not dire t bu f <br />Model: -P /76 1 (2 — L �bur <br />`0 Pk) <br />El Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />X91 -octane UST ❑ diesel UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Bravo float and chain replacement <br />❑ Automatic tank gauge (ATG) replacement <br />Dispenser: Grade: <br />Model: <br />Dispenser: Grade: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />Dispenser: Grade: <br />❑ 91 -octane UST <br />❑ diesel UST <br />Dispenser: Grade: <br />❑ other: <br />*This applies only if contractor has all required certifications. <br />PR#: `, <br />6 a-319 3� <br />PE: <br />SC: Q98 <br />Accepted By/ <br />Assigned To: <br />Date: 7 �•, / <br />EHD 23-05 Rev. 07/20/12 <br />UST RETROFIT VE IFICATI FORN <br />9) <br />