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ENVIRONM&TAL HEALTH DERARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Facility Name: Address: Facility • Title: d jd 0 0 If' Contact: n Contractor .>- Contractor Name: Q Address: �J v License Number: Class&ojQ5 Contractor NuPhone#: gj) -71q"14 Insurer: 1 _ Workers' ryry�� 3 Comp.#: QD ICC Tech: IQ, Exp. Date: ICC Installer: Exp. Date: Manufacturer` Exp.Date: Training: Y �'- ® Indicate below type of work to be performed. Check all that apply. Sensor replacement ❑ Sensor replacement Model: 42-0 Model: 0 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 1/2 ❑dispenser 3/4 ❑ dispenser 5/6 ❑ dis enser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: xa-a n n ❑ other: ❑ Leak detector replacement ❑ Leak detector replacement Model: Model: ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) Model: Model: ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement Dispenser: Grade: Model: Dispenser: Grade: ❑ 87-octane UST ❑ 89-octane UST Dispenser: Grade: ❑ 91-octane UST ❑ diesel UST Dispenser: Grade: ❑ other: *This applies only if contractor has all required certifications. PR#: PE: SC: 098 Accepted By/ Date: 7 Assigned To:S J-7 (l1 23-05 Rev.07/16/12 UST RETROFIT RIFIC TIO FORM