Laserfiche WebLink
ENVIRONMENTAL HEALTH DEIPiARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton, Stockton, California 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT PERMIT WITH INSPECTOR ALREADY ONSITE"` <br /> ;Facili Information <br /> Facility 1 LC7� Faci lily I' <br /> Name T-Y L Address I*�1 <br /> Facility Title <br /> Contact <br /> Contractor.Information <br /> Contractor gyn Contractor <br /> Name r(. — Address I Z <br /> CA License 3Class & Contractor Z <br /> number hone# ea <br /> Insurer T e corn # S&4e t6L coIIIb <br /> ICC Tech -MO <br /> ech t Exp. Date <br /> ICC Installer Exp. Date <br /> Indicate below type of work to be performed. Check all that apply. I[ <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> c 87 piping sump c 87 fill sump 1187 piping sump o 87 fill sump <br /> c 89 piping sump c 89 fill sump c 89 piping sump c 89 fill sump <br /> c 91 piping sump o 91 fill sump c 91 piping sump 1191 fill sump <br /> c diesel piping sump c diesel fill sump c diesel piping sump c diesel fill sump <br /> c dispenser 1/2 c dispenser 3/4 c dispenser 1/2 c dispenser 3/4 <br /> c dispenser 5/6 c dispenser 7/8 c dispenser 5/6 o dispenser 7/8 <br /> 0 other: c other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> c 87-octane UST c 89-octane UST c 87-octane UST c 89-octane UST <br /> c 91-octane UST c diesel UST o 91-octane UST c diesel UST <br /> c other: c other: <br /> Spill container replacement(not direct bury ' Spill container replacement(not direct bury) <br /> Model: (�'SI)bO�III(r r. XFk" Model: <br /> ')X87-octanelc 89-octane UST c 87-octane UST c 89-octane UST <br /> c 91-octane UST c diesel UST c 91-octane UST c diesel UST <br /> 0 other: c other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: c 87-octane UST c 89-octane UST <br /> Dispenser: Grade: o 91-octane UST c diesel UST <br /> Dispenser: Grade: o other: <br /> *This application applies only during routine inspections or monitoring certifications. <br /> SR#: PE: 2308 sc: 098 Accepted By/ <br /> Assigned To: l <br />