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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* FacilityInformation Facility'' /LL�� Name: Eym t �5 L�-ewI fti( S vt-e, rYll ll Address: Facility `T�V �. �ii{�i�GO NOt, c�=fC�1 JI U Facility.�-! !AL ✓ i u n me l Title:C; yv j�t,.�./^ Contact: Gf C �„_L '�J "T Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement LIF,.0la ❑ 87 piping sump 1187 fill sump Contractor Information ❑ 91 piping sump Contractor C �„_L '�J "T ❑ diesel fill sump Contractor 1,ly �h_ol S - � q�� 3 Name: 'CU a ❑ other: Address: X11 7 1`I CA License Number: 31I3 -'S Class: Leak detector replacement / Contractor Phone #: M tel 44 _ O` 13 Insurer: *1 -octane UST ❑ diesel UST Workers' Comp. #: ICC Tech: J>LviA WIYLV_(...af Exp. Date: 3/t tf ICC Installer: ❑ diesel UST ❑ other: Exp. Date: ❑ Automatic tank gauge (ATG) replacement Manufacturer v 1 ❑ 87 -octane UST Exp. Date: Ill / )S / V-0147 Training: ❑ other: Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement LIF,.0la ❑ 87 piping sump 1187 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 n dispenser 7/8 ❑ other: ❑ dispenser 3/4 ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST D 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: Dispenser: Grade: Dispenser: Grade: Dispenser: Grade: *This applies only if contractor has all required certifications. ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 other: Leak detector replacement / Model: 0 0 1,1) 2_15W ❑ 87 -octane UST ❑ 89 -octane UST *1 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST D 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: PP- OaZ) 17 (o � I PE: I SC: 098 I Assignted To, 1 I Date: I�