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0 0 <br /> 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 /> — s <br /> �• ��li� ��.x�- W. �.� "��`� cll Information. m <br /> Facilityfi��/11r� J C�trlS �l l�tvlr Facility 4WU f Fyem,&t S}, rVLVt0r1 <br /> Name: Address: <br /> Facility 12� ^�',���g p Title: (��-jvk �(,/' <br /> Contact: i ew i W <br /> 'Contractor(I031] OJ_ 2A WA <br /> ContractorContractor <br /> Name: � (� " W11 N(\ta'1 a Address: 4I l,4 2n d S(03a <br /> CA License 1 5 Class: r Contractor L041 - 1`+LA -U Il 2, <br /> Number: �� 3 �U ! 1 Phone#: <br /> Workers' <br /> Insurer: Comp.#: <br /> ICC Tech: _2 et IN �1 M me Exp.Date: /Ll I q <br /> ICC Installer: Exp.Date: <br /> Manufacturer ` r; 1 )�Cl <br /> Trainin : - I q T J/3I Exp.Date: 1�" / / <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 /> KLeak detector replacement 111 IeR— ` ,� ❑ Leak detector replacement <br /> Model: V MI VN Lid Zy0© SC(la-tlgU` 1"I Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane LIST diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑other: ❑ 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 ❑ 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. Jf <br /> t�Z?� i PE: 3(�( SC: 098 Accepted By/ Date: >C -I <br /> PR#: Kms- Assigned T <br /> EHD 23-05 Rev.07/20/12 6 <br /> r-e UST RETROFIT VERIFICATION FORM <br />