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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 4 r <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE*' y, T <br /> Facilltv Information <br /> Facilityt �, Facility <br /> Name: c Address: <br /> Facility 11, <br /> Contact: �j t Title: (- <br /> Contractor Information <br /> Contractor Contractor [ p 1 <br /> Name: t i -V& Address: <br /> CA License Contractor <br /> 21AClass: <br /> Number: �4 <br /> � cr.-t Phone#: <br /> Insurer: f^ \ Workers' <br /> a.t 01-\4IA Comp.#: l { <br /> IGC Tech: -f Exp.Date: <br /> ICC Installer: ! Exp.Date: t. <br /> Manufacturers <br /> Train ng: . Exp.Date: <br /> Indicken'sor <br /> l type of work to be performed. Check all that apply. <br /> replacement ❑ Sensor replacement <br /> Model: Model: <br /> n 87 piping sump ❑ 87 fill sump n 87 piping sump n 87 fill sump <br /> * 89 piping sump c 89 fill sump U 89 piping sump ❑ 89 fill sump <br /> ❑91 piping sump 1191 fill sump c 91 piping sump ❑ 91 fill sump <br /> ❑diesel piping sump n diesel fill sump ❑diesel piping sump ❑diesel fill sump <br /> a dispenser 1/2 u dispenser 3/4 ❑dispenser 1/2 [:dispenser 3/4 <br /> ❑dispenser 5/6 n dispenser 7/8 ❑dispenser 5/6 c dispenser 7/8 <br /> ��❑other: ` o other: <br /> 5/Leak detector replacement CI b�50ok0(01 '* ❑ Leak detector replacement <br /> Madel: r PA - i- b. Model: <br /> x187-octane USA-r4 ❑89-octane UST u 87-octane UST n 89-octane UST <br /> to 91-octane US ❑diesel UST ❑91-octane UST n diesel UST <br /> n other: n other. <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> n 87-octane UST o 89-octane UST n 87-octane UST n 89-octane UST <br /> n 91-octane UST o diesel UST -j 91-octane UST n 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 ii 89-octane UST <br /> Dispenser. Grade: n 91-octane UST ❑ diesel UST <br /> Dispenser: Grade: ❑other. <br /> `This applies only if contractor has all required certifications. <br /> IN `�v' SC: O9$ Accepted By/ <br /> PR#: r �!� q PE:.!i Assigned To: UC—� }� <br /> EHD 23-05 Rev.07/20/12 off �TRETRI: <br /> FITRIFI TION FORM <br />