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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 />UNDERGROUND STORAGE TANK <br />RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br />Facility Q Facility / f' <br />Name: 6 1`i7')I � � `"e- fy / Address: l�% Z_ I ,U M W/ <br />Facility �n1 <br />,._._ /,),,A I .n n IV, Q C .f/n .. 0 fi, i . nt „ n Title: vy <br />Contractor <br />�� „ • <br />ontra V - <br />Z �C� "e�� /� <br />Name: <br />`P- CGU <br />J l <br />CA License <br />C <br />Class: 9,� 00 <br />Contractor <br />Number: <br />Phone #: <br />Insurer:W <br />1A (PM <br />T <br />�j h <br />kers' <br />C #: <br />Te <br />Exp. Date: <br />ICC Installer: <br />Exp. Date: <br />Manufacturer <br />Exp. Date: <br />Training: <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 <br />❑ 87 fill sump <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ 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 <br />❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />❑ Spill container replacement (not direct bury) <br />Model: <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />`ravo float and c ain replacement <br />El Automatic tank gauge (ATG) replacement <br />Dispenser: 3 i <br />Grade: oeLtS- <br />Model: <br />Dispenser: <br />Grade: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />Dispenser: <br />Grade: <br />❑ 91 -octane UST <br />❑ diesel UST <br />Dispenser: <br />Grade: <br />❑ other: <br />*This applies only if contractor has all required certifications. <br />PR#:Accepted By/ D a, ...) I I PE: ?� I SC: 098 I Assigned To: T I Date: a5 6 ) q <br />EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORK <br />