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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 />FaClll ,Inforrnatio'n <br />Facilityr Facility „7, 7 ell, <br />' )_ th r` <br />Name: J 1 Address: Y� <br />Facility Title: <br />Contact: 150e P11 fA h <br />x p. v 4 x °Contr cto`Irtform.s <br />Contractor <br />Address: <br />P O� <br />a'f Ks a <br />)CC' fa �Se kl 0 S� <br />Contract <br />Name: P1hYtACC'. COw l,wi Se 1'V rtes <br />CA License <br />Number: <br />class: b 40 <br />Contracto <br />Phone #:(40k-) <br />d� d <br />Insurer: vC)SOh <br />✓1 SJ�Lt✓1(� <br />r-� <br />VOYYt fe4 in <br />Workers' <br />Com . #: <br />itel"i <br />y <br />1 <br />ICC Tech: �"� F�' <br />(20),6ie <br />Model: <br />Exp. Date: <br />o? <br />❑ 89 -octane UST <br />ICC Installer: <br />❑ diesel UST <br />❑ other: <br />Exp. Date: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />ManufacturerS� F r <br />1 <br />h r <br />vm <br />Exp. Date: <br />al•t Q/,?0%d' <br />Trainin <br />❑ Automatic tank gauge <br />(ATG) replacement <br />Model: <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Grade: _ <br />Model: <br />Grade: _ <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />OW <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />*This applies only if contractor has all required certifications. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />kf Leak detector replacement <br />Model: V #IT LW <br />OW <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />it diesel UST <br />❑ other: <br />❑ Spill container replacement <br />(not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge <br />(ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />Accepted F <br />PR#: I PE: I SC: 098 I Ass gned To: ByDate: <br />EHD 23-05 Rev. 07/16/12 UST RETROFIT VERI <br />