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ENVIRONMPNTAL 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 /> Facility Information <br /> Facilit Facility <br /> NameY Address: <br /> Facility <br /> Contact: `\Ck \ O Title: r <br /> Contractor Information <br /> Contractor11 Contractor <br /> Name: Address: O �1 <br /> CA License r�^^'1t Class: Contractor <br /> Number: Q d 1 Phone#: <br /> Workers' <br /> Insurer: 5AakC4Ln& Come.#: 1 04 S3 <br /> ICC Tech: C ` 1t Exp.Date: s -•� <br /> ICC Installer: JACExp. Date: / <br /> Manufacturer Exp. Date: — <br /> Training: Q(' <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> Model: O';aoq 117 — OCA Model: <br /> D 87 piping sump ❑ 87 fill sump D 87 piping sump o 87 fill sump <br /> D 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump D 91 fill sump ❑ 91 piping sump D 91 fill sump <br /> ❑ diesel piping sump D diesel fill sump ❑ diesel piping sump D diesel fill sump <br /> D dispenser 1/2 D dispenser 3/4 D dispenser 1/2 ❑dispenser 3/4 <br /> D dispenser 5/6 ❑ dispenser 7/8 D dispenser 5/6 ❑ dispenser 7/8 <br /> �eother: � 1 - S(hcc 4 Sensor Alk A4ue. D other: <br /> ii kt,!•2 1Zebt..ti&\l4CuutA �n5ot <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 D 91-octane UST D diesel UST <br /> • other: D other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> D 87-octane UST D 89-octane UST D 87-octane UST D 89-octane UST <br /> D 91-octane UST D diesel UST D 91-octane UST D diesel UST <br /> D other: D other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: D 87-octane UST D 89-octane UST <br /> Dispenser: Grade: D 91-octane UST D diesel UST <br /> Dispenser: Grade: D other: <br /> *This applies only if contractor has all required certifications. r� <br /> PR#: � jC��$�a PE: SC: 098 Accepted By/ Date: <br /> Assigned To: <br /> EHD23-05 Rev.07/16/12 US TROFIT VERIFICATION FORM <br />