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0 01 <br />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 />Indicate below type of work to be performed. Check all that apply. <br />IR Sensor replacement <br />Grade: <br />Model: 87A Product Smart Sensor <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 112 <br />❑ dispenser 314 <br />❑ dispenser 516 <br />❑ dispenser 718 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST a 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <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 />1189 piping sump <br />❑ 91 piping sump <br />❑ diesel piping sump <br />❑ dispenser 112 <br />❑ dispenser 516 <br />❑ other: <br />❑ 87 fill sump <br />❑ 89 fill sump <br />❑ 91 fill sump <br />❑ diesel fill sump <br />❑ dispenser 314 <br />❑ dispenser 718 <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other.- <br />El <br />ther: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />PR#: 0527629 PE: 2300 sc: 098 I <br />Accepted By/ Thuy Tran Dace: Aug 21, 2013 <br />=H❑ 23-05 Rev. 07!24112 <br />UST RETROFIT VERIFICATION FORM <br />