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ENVIRONKA!NTAL HEALTH DE*rARTMENT <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 Information;:. <br /> Facility Facility 00 <br /> �v <br /> Name: Address: <br /> Facility <br /> Contact: Title: <br /> _ Contractor Information <br /> COGtfaClor Contractor -1^1 <br /> Name t i L �c l( Address: I �� �N1 M C/P(Z tjF/i7 <br /> Nu License ZI r _0 Class: Phone#:Contractor 51 d-- <br /> Number: �O <br /> Insurer: n Com#: WCAIQjOq� <br /> ICC Tech: breu:t Exp. Date: - <br /> ICC Installer: �� QAExp.Date: - 'S <br /> Manufacturer Exp.Date: <br /> Training: V/ n� b-fYVy+ _V <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump 1187 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump 1191 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 /> w t ❑ other: ❑ other: <br /> yLeak detector replacement Leak detector replacement <br /> d Model: Ul # 140It qb+ Model: la�I4C7� <br /> 47-octane UST ❑ 89-octane UST Li87-octane UST ❑ 89-octane UST <br /> 1-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 D 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 /> PR#: U51 PE: �Lbb sC: 098 Asslgn ed To/ Q'21I { Dater <br /> EHD 23-05 Rev.07/16/12 [� UST RETROFIT VERIFICATION FO M <br />