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ENVIROWNTAL HEALTH DEARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton, Stockton, CA 95205-6232 <br /> I 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 I (jJ + D <br /> Name: '�` 3� Z " Address: '( <br /> Facility Title: <br /> Contact: <br /> Contractor Information <br /> Contractor _ Contractor /D f. <br /> \ 0.��InlJ Address: <br /> Name: / IL�V-('� • ' �/ <br /> CA License �r 1 '? D Class: ft <br /> _ _ /f_ <br /> Number: `i' J Phone#: 4 <br /> f Workers' <br /> Insurer: owe C Com <br /> ICC Toch: �a_rr0 C Exp.Date:.rr <br /> ICC Installer. - Exp. Date: <br /> Manufacturer A/1 f ?� Exp. Date: <br /> in �_ 1 <br /> Train <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump <br /> ❑ diesel piping sump ❑diesel fill sump ❑ diesel piping sump ❑ diesel fill sump <br /> ❑ dispenser 1/2 ❑ dispenser 3/4 ❑dispenser 1/2 ❑ dispenser 3/4 <br /> ❑dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> ❑ other: ❑ other: <br /> Leak detector replacement ❑ Leak detector replacement <br /> Model: UML °ta LD207 3N:{Z0 j Bj I Model: <br /> ,07-octane UST o8 ctane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑other: ❑ other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑ other: ❑ other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge(ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: ❑ 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST ❑diesel UST <br /> Dispenser: Grade: ❑ other: <br /> *This applies only if contractor has all required certifications. <br /> 2 Accepted To: Date: 0j <br /> PR#: Q 33 PE: 2f`4 I SC: X98 Assigned To: �O P <br /> EHD 23-05 Rev.07/16/12 v T RETROFIT VERIFICATION FORM <br />