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.,--NV1R0NMEtTAL HEALTH DEARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-341 <br />Facility Information <br />Grade: <br />Facility <br />Name: '7 Ele!LeA 54-6 Ce, -44-.3 2 Z <br />Facility <br />Address & aa <br />Facility <br />S- I I <br />Title: <br />Pra d h <br />Contact: <br />r-%, i _-pe e. <br />Indicate below type of work to be performed. Check all that apply. <br />[9 Sensor replacement <br />Grade: <br />Model: 224 3 2 6 9 <br />Contractor <br />Information <br />Ei 89 piping sump <br />o 89 fill sump <br />ContractorContractor <br />Name: <br />—r.1 <br />o diesel piping sump <br />o diesel fill sump <br />Address: <br />10-2� <br />sS i hkLj 5LI) ic- A 9 <br />CA License <br />Number: <br />r7 <br />f-r— <br />Class: �hN <br />Contractor <br />Phone #: <br />3 C S - 2- <br />Insurer:Workers' <br />a V <br />Comp. #: <br />WC A <br />I C� � <br />ICC Tech: <br />i0 a -S <br />PQ� ) 4 YZ 0 <br />Exp. Date: <br />1/7 <br />ICC Installer: <br />N1 CO �43 <br />Exp. Date: <br />Manufacturer, <br />Training: <br />\� -16 <br />-0 -t <br />Date: <br />2,12 <br />Indicate below type of work to be performed. Check all that apply. <br />[9 Sensor replacement <br />Grade: <br />Model: 224 3 2 6 9 <br />o 87 piping sump <br />o 87 fill sump <br />Ei 89 piping sump <br />o 89 fill sump <br />W, vr91 piping sump <br />"l fill sump <br />o diesel piping sump <br />o diesel fill sump <br />Ei dispenser 1/2 <br />Ei dispenser 3/4 <br />• dispenser 5/6 <br />[:1 dispenser 7/q <br />• other: r -,-,v 14 <br />V <br />f-r— <br />El Leak detector replacement <br />Model: <br />o 87 -octane LIST <br />ii 91 -octane LIST <br />o other: <br />Ei 89 -octane LIST <br />i:i diesel LIST <br />El Spill container replacement (not direct bury) <br />Model: <br />• 87 -octane LIST o 89 -octane LIST <br />• 91 -octane LIST ii diesel LIST <br />• other: <br />0 Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />o 87 piping sump <br />o 87 fill sump <br />Ei 89 piping sump <br />o 89 fill sump <br />* 91 piping sump <br />0 91 fill sump <br />* diesel piping sump <br />o diesel fill sump <br />Ei dispenser 1/2 <br />o dispenser 3/4 <br />• dispenser 5/6 <br />o dispenser 7/8 <br />• other: <br />El Leak detector replacement <br />Model: <br />ci 87 -octane LIST <br />i:i 91 -octane LIST <br />o other: <br />• 89 -octane LIST <br />• diesel LIST <br />0 Spill container replacement (not direct bury) <br />Model: <br />• 87 -octane LIST o 89 -octane LIST <br />• 91 -octane LIST Ei diesel LIST <br />• other: <br />0 Automatic tank gauge (ATG) replacement <br />Model: <br />i:i 87 -octane LIST <br />o 91 -octane LIST <br />Ei other: <br />*This applies only if contractor has all required certifications. <br />I — 1 1— ^no I Accepted By/ <br />-PR* 05-072e PE .2 U 1 Se-. olig V I' &keda rfae-�? <br />• 89 -octane LIST <br />• diesel LIST <br />��Z <br />WIM <br />IMIll <br />