Laserfiche WebLink
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 /> Facili Information <br /> Facility n `� y� Facility <br /> Name: A �"m �S (.} Address: <br /> Facility (�" Title: Q4y'nz <br /> Contact: a 1+ Y� <br /> Contractor Information <br /> Contractor G-wk 1 u� � {�,.,,,� AddConress: lb�` �^w Kin ciourt <br /> Name: C�` .�` � Address: iJ 1 `1 I <br /> CA License 1 L� Class: Contractor o <br /> C <br /> Number: L Phone#: 5 ~ 4 <br /> s` <br /> Insurer. Worker <br /> ty co- 5(x-1(9 Com .s' <br /> ICC Tech: # 52-5 0451 Exp.Date: L4 ' y� 0k6(, <br /> ICC Installer: r3 2.50g5{ Exp.Date: I a �-L D-0I <br /> Manufacturer �(� �� Exp.Date: �t1�a �aQl"I <br /> Training: l <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> Madel; Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump o 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump <br /> o diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump <br /> o dispenser 112 o dispenser 314 L dispenser 112 ❑ dispenser 314 <br /> ❑ dispenser 516 o dispenser 718 Ll dispenser 516 ❑ dispenser 718 <br /> )(other: %Clr a 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 Li 91-octane UST ❑ diesel UST <br /> ❑ other: c other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> a 87-octane UST ❑ 89-octane UST ❑ 87-octane UST o 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST o 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 o 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 /> � <br /> a PE: I SC: 098 Accepted By/ Date: <br /> C6 '1 <br /> PR#: I I-) Assigned to-3'y <br /> EHD 23-05 Rev.07/20112 UST RETROFIT VERIFICATION FORM <br />