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ENVIRONMENTAL 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 /> Facifit Information <br /> Facility Facility <br /> Name: �C.!- � � �1 S Address: .1Jv✓ W <br /> f�� ,n�F <br /> Facility �7 i t`j►/ Title: kAjif,W1P�r� [a, <br /> Contact: <br /> Contractor Information <br /> Contractor �y Contractor \ p_n., c <br /> Name: �"�'t/� C l) ���C1� Address. <br /> CA License Y. 77,� Class: Contractor <br /> Number: V Phone#: <br /> Insurer: pp�rl1�IL t/�S Workers' <br /> {1& I � e Comp.#: <br /> ICC Tech: 4_� +f �/} Exp. Date: �� j 7vt <br /> ICC Installer: Exp. Date: <br /> Manufacturer ,� Exp. Date: -7000 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> Model- I um L,6 Model: <br /> ❑ 87 piping sump ❑ 87 fill sump r- 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fila sump ❑ 89 piping sump ❑ 89 fill sump <br /> 0 91 piping sump ❑ 91 fiil sump ❑ 91 piping sump ❑ 91 fill sump <br /> ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump n diesel fill sump <br /> ❑ dispenser 112 ❑ dispenser 314 ❑ dispenser 112 ❑ dispenser 314 <br /> ❑ dispenser 516 ❑ dispenser 718 ❑ dispenser 516 ❑ dispenser 7/8 <br /> 1other: 1y C Sim' nl ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST n 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST -:i diesel UST <br /> ❑ other: ❑ other: <br /> ❑ Spill container replacement (not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> Li 87-octane UST ❑ 89-octane UST a 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: Li 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 /> dn� Al <br /> J <br /> /_.1 <br /> ' SC: X98 Accepted By/ Date: <br /> PR#: .n PE: �Jt�t'ti Assigned To: <br /> �!`, .~ I S <br /> EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM <br />