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ENVIRONMATAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1 868 E. Hazelton, Stockton, CA 95205-6232 <br />Telephone: (209) 465-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK <br />RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE <br />Facility Information <br />Facility <br />Name: <br />r' G.5 4- <br />Facility %S R V ,-, <br />Address: <br />Facility / <br />Contact: f f la <br />Title: <br />Indicate below type of work to be performed. Check all that apply. <br />Sensor replace <br />Model b2, -7,0C -IN LK5Z� <br />__--�r87 piping sump <br />Contractor Information <br />❑ 89 piping sump <br />Contractor ,n. <br />% <br />❑ 91 piping sump <br />❑ 91 fill sump <br />Contractor <br />❑ diesel fill sump <br />Name: / r� <br />4�.! ,,,1 <br />❑ dispenser 516 <br />Address: <br />,aS <br />CA License <br />Class: <br />Contractor <br />57 <br />Number: <br />❑ diesel UST <br />❑ other: <br />Phone #: <br />o- <br />Insurer: <br />n 87 -octane UST <br />❑ 89 -octane UST <br />Workers' <br />❑ diesel UST <br />ICC Tech: � <br />vim% <br />ElAutomatic tank gauge (ATG) replacement <br />Exp. Date: <br />ICG Installer: <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />Exp. Date: <br />❑ other: <br />Manufacturer <br />-Training: V <br />Exp. Date: <br />r <br />Indicate below type of work to be performed. Check all that apply. <br />Sensor replace <br />Model b2, -7,0C -IN LK5Z� <br />__--�r87 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 />❑ 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 ❑ 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 />❑ 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 5/6 <br />❑ dispenser 718 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />n 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />ther:❑ <br />❑ other.- <br />ElAutomatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#: PE: SC: Accepted Byl <br />X231 y $ Z3 098 Assigned T Date: C` <br />EH 23-05 Rev. 07/16/12 UST RETROFIT VE IFICl9Tll TION FORM <br />