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ENVIRONME'NO TAL HEALTH DEFARTMENT <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 /> _ - - Facili Information <br /> Facility Facility <br /> Name: 011 Address: <br /> Facility Title: <br /> Contact: <br /> Contractor Information <br /> Contractor Contractor <br /> Name: Address: U - <br /> CA License '3 h Class: Contractor ' <br /> Number: V Phone#: <br /> Insurer: Workers' Z <br /> Com .#: <br /> ICC Tech: KPIExp.Date: �— <br /> ICC Installer: - Exp. Date: <br /> Manufacturer Exp.Date: <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> —PLSensor repla ement �P*W 4; 0 Sensor replacement <br /> .Model: 1/&aa &zmQ5gQ Model: <br /> ci 87 piping sump o 87 fill sump o 87 piping sump o 87 fill sump <br /> 0 89 piping sump ❑ 89 fill sump o 89 piping sump o 89 fill sump <br /> ❑ 91 piping sump o 91 fill sump ❑ 91 piping sump ❑ 91 fill sump <br /> ❑diesel piping sump o diesel fill sump ❑diesel piping sump ❑ diesel fill sump <br /> ❑ dispenser 1/2 o dispenser 3/4 o dispenser 1/2 o dispenser 3/4 <br /> o dispenser 5/ dispenser 7/8 o dispenser 5/6 ❑ dispenser 7/8 <br /> ❑ other: 1fYl�'� �j. _ AAr ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model <br /> o 87-octane UST o 89-octane UST ❑ 87-octane UST o 89-octane UST <br /> 0 91-octane UST o diesel UST o 91-octane UST ❑ diesel UST <br /> 0 other: ❑ other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> 0 87-octane UST ❑ 89-octane UST o 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST o diesel UST o 91-octane UST o diesel UST <br /> 0 other: ❑ other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: o 87-octane UST o 89-octane UST <br /> Dispenser: Grade: o 91-octane UST o diesel UST <br /> Dispenser: Grade: o other: <br /> *This applies only if contractor has all required certifications. O �� <br /> PR#: �°.3e?q � PE:� 2 6 I SC: �9$ Assigned ToAccepted / _f k 7 Date: <br /> EHD 23-05 Rev.07/16/12 /'7 UST RETROFIT VERIFICATION FORM <br />