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ENVIRONMENTAL HEALTH DEPARTMENT 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* Indicate below type of work to be performed. Check all that apply. Sensor rtej� ceNiq-sw--2m: s�_�* 1ST -78 Model: V ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump '1 piping sump ❑ 91 fill sump rdiesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model ❑ 87-oct2ne UST ❑ 89-oct2ne UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ Contractor Information' Contractor Dispenser: Contractor 4-2-36Name: Dispenser: Grade: _ dress: CA License 5 (fA7 Class: Contractor Number: ✓ J Phone #: Model: V\Jprkers' Insurer:. ❑ 89 -octane UST mp. #: 10 ICC Tech: km ❑ other: I �/ Exp. Date: ICC Installer: Exp. Date: ❑ 89 -octane UST Manufacturer ❑ diesel UST Exp. Date: Training: Indicate below type of work to be performed. Check all that apply. Sensor rtej� ceNiq-sw--2m: s�_�* 1ST -78 Model: V ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump '1 piping sump ❑ 91 fill sump rdiesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model ❑ 87-oct2ne UST ❑ 89-oct2ne UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ *This applies only if contractor has all required certifications. ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: 65za64 PE: -3,5 SC: 098 Accepted By/ Date: 6-1. --- Assigned To: EHD 23-05 Rev. 07/16/12 UST RETROFIT VERIFICATION FORM