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ENVIRONMfNTAL HEALTH DE?A' RTMENT <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 /> Addre -. <br /> Facility Y / ��* (. w6 6 <br /> Name: ss: tL� a� 1/�i <br /> Facility Title: <br /> Contact: <br /> xv 4 =..Gontracto lnformat�onm <br /> ' <br /> Contractor Contractor ^ <br /> Name: Address: t <br /> Class: <br /> CA License n Contractor � ) <br /> Number: (0nsa... Phone#: '-'C <br /> Workers' <br /> Insurer: q0 ONG <br /> omp.#: <br /> ICC Tech: (` Exp.Date: <br /> ICC Installer: f° Exp.Date: <br /> =ManufaLcture=rExp.Date: i <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ 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 /> eak detector replacement El Leak detector replacement <br /> Model: r (Vfva,) Model: <br /> ❑ 87-octane UST ❑ 8 -octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑ other: 10 6 1,5 r3l ❑ other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <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 /> ❑ Bravo float and chain replacement El Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: ❑ 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 /> PR#: PE: SC: 098 Accepted By/ Date: <br /> Assigned To: ek0-1 Ob fV d7�9 1 -4, ---ti-W� <br /> EHD 23-05 Rev.07/16/12 1 UST RETROFIT VERIFICATION FORIV <br />