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ENVIRONMENTAL <br />`A 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 />a a <br />FacilityOTAddress: C� <br />r <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />0 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />Contractor <br />n Contractor <br />❑ 91 fill sump <br />Name: <br />Y Address: <br />O <br />CA License <br />Number: <br />Class: Contractor <br />Phone #: <br />❑ dispenser 7/8 <br />❑ other: <br />orkers' <br />RR <br />Irer: <br />nsu <br />m .#: <br />V <br />ICC Tech: <br />xp. Date: <br />❑ diesel UST <br />ICC Installer: <br />Exp. Date: <br />614 <br />Manufacturer <br />Exp. Date: <br />❑ 87 -octane UST <br />Training: <br />❑ 91 -octane UST <br />❑ diesel UST <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />0 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 />UST RETROFIT VERIFICATION FORM <br />❑ Leak detector replacement <br />Model: <br />_ <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 jgt gjd <br />Dispenser: ( Grade:LA <br />Dispenser: f Grade: <br />Dispenser: Grade: <br />Dispenser: 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 />UST RETROFIT VERIFICATION FORM <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 />❑ Automatic tank gauge (ATG) <br />replacement <br />Model: <br />o 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />1 <br />SC: 098 <br />AcceptedTtLo <br />Assigned To:o: <br />I Date: L'i <br />EHD 23-05 Rev. 07/16/12 <br />UST RETROFIT VERIFICATION FORM <br />