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ENVIRONME�VTAL HEALTH DEPARTMENT <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 />Facility Information.. <br />Facility <br />�.`��1 ��2. v+ U'l (h-� f1 4::x <br />Facility <br />P <br />CA LicenseContractor <br />Name: Q i <br />�' C' (\ }� <br />Address: / <br />S <br />taCl( 7 <br />FacilityTitle: <br />` <br />� <br />Phone #: <br />Insurer:Workers' <br />Contact: C <br />j <br />ICC Tech: <br />;64 Q �` <br />Exp. Date: <br />, Contractor Information <br />Contractor <br />Name: <br />�.`��1 ��2. v+ U'l (h-� f1 4::x <br />Contractor <br />Address: <br />qui �� y� C <br />,J <br />CA LicenseContractor <br />So <br />Class: <br />❑ dispenser 1/2 <br />' S I t \ � ^� C.J24�4-, X--a� i h; <br />'7.aNumber: <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />Phone #: <br />to c 10 <br />Insurer:Workers' <br />V� �� Su�;�c <br />op. #: <br />ICC Tech: <br />;64 Q �` <br />Exp. Date: <br />❑ other: <br />ICC Installer: <br />❑ Spill container replacement (not direct bury) <br />Exp. Date: <br />Manufacturer <br />❑ 89 -octane UST <br />Exp. Date:y- <br />❑ diesel UST <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 <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 />❑ 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 ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <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 />Automatic tank gauge (ATG) replacement <br />- Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />other: &Agn rbLAb <br />PR#:ODa <br />L� <br />I PE: ?,3 (V ` <br />C <br />SC: 09$ <br />Accepted By/ <br />I Assigned To: TlcalwoNy� <br />Date: -7 — 7,)k <br />EHD 23-05 Rev. 07/16` <br />2 <br />USIJETROFIT VERIFICATION FORM <br />