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ENVIRONM&TAL 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 />FacilityFacility <br />Name: r L. \ C, A -C6, L•(3C) A- <br />Address: tia <br />1 <br />Facility ` �l. <br />/'``J\ 1 <br />Title: cock (> � <br />Contact: i <br />Contractor <br />Indicate below type of work to be performed. Check all that apply. <br />1� Sensor replacement <br />Grade: _ <br />Contractor Information <br />)C ,�)c.I -� _)V <br />Contractor1 <br />n <br />❑ 87 fill sump <br />Contractor <br />\`` C <br />Name: , t <br />❑ 91 fill sump <br />Address: <br />ti1 <br />CA License <br />❑ dispenser 314 <br />Class: <br />Contractor <br />i 9T' <br />Number: <br />i C7 <br />Phone #: <br />Insurer: <br />C* \- 4 <br />Workers' <br />Comp. #: g, <br />C_ <br />ICC Tech: <br />Exp. Date: <br />1-1 <br />7Sa <br />ICC Installer: <br />S o o,A <br />Exp. Date: <br />IS <br />Manufacturer <br />Exp. Date: <br />Training: <br />t- o_ <br />Indicate below type of work to be performed. Check all that apply. <br />1� Sensor replacement <br />Grade: _ <br />Model: 11Z GQ <br />)C ,�)c.I -� _)V <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />x-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 />ST <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />El 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 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 ❑ 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#: {) � Accepted By/ <br />�ti �' Assigned To: G --Q {'{�- Date: �-�•- ��1� <br />D23-06 Rev. 07116!12 UST RETROFIT VERIFICATION FOI <br />UM <br />