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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 /> Facilit 1'nformatidn. .t`� <br /> Facility l I Facility , r / y �r <br /> Name: t _ i.. > " ti � �� „�, r) j� C fa ( t �.i ( C_r � i Address: <r ((.1 2 t . I � ^ c Gr <br /> Facility <br /> Contact: i t +z f` 1� '� Title: <br /> r a . ,c,. :- ✓ `, ' ',: , 1 '? ' �,ar . ;; 3„. t cCii%itractbr'Ihfoi'_rotio -77,;F , :' c , � <br /> - .- <br /> Contractor it Contractor , <br /> Name: Al 1 `i( {' CPI-2 i t (1 � ty { Address: i <br /> CA License > ,- Contractor <br /> Number'. t.o ' �% ; N ` p Class: <br /> 1 f� Phone #: <br /> Insurer: rk Workers' ~} ! <br /> � r� tr : t �: ti . . ;� 1ii" Mti .1r iatG � sn 1 <br /> Come. #: 64) <br /> ICC <br /> ICC Tech . i Exp. Date: <br /> v� L l ,�to f C <br /> ICC Installer. Exp. Date: <br /> Manufacturer r" <br /> Training : Exp. Date: i_ a ` ' �. <br /> Indicate below type of work to be performed . Check all that apply. <br /> El Sensor replacement El Sensor replacement <br /> Model : � ` C� .) ; ;'; se, � 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 /> Bother: , � �. i _ P/` '. r1 ” i*1 � i � ( � .� � ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <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 /> ❑ 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. <br /> PRA: C".� / i , 1 L J` ? PE 1 t 1 SC : (] 9 $ Accepted By/ Date: — <br /> Y 1 . � . ' r .x'141 1 <br /> EHD 23-05 Rev. 07/16/12 ' UST,RETROFIT VERIFICATION /FORM <br />