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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 /> Facility Information <br /> Facility TT Facility <br /> Name: L a`o n;a.) rin Address: <br /> Facility Title: <br /> Contact: <br /> Contractor Information <br /> Contractort \ \ Contractor c <br /> Name: �,J .r Address: S <br /> CA License Clas . ContraPhone#ctor 3 e) <br /> Number: $ : �� — I <br /> wor e s 9113 3 <br /> Insurer: <br /> ICC Tech: Exp.Date: Ill <br /> ICC Installer: Exp. Date: <br /> Ma3 nufacturer Exp.Date: O� 19 <br /> Trainin <br /> Indicate bel w type of work to be performed. Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> Model: f)�- q LIZ'?n —24NS/ Model: <br /> b,e7 piping sump o 81 fill sump ❑ 87 piping sump o 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump o 91 piping sump ❑ 91 fill sump <br /> o diesel piping sump o diesel fill sump o diesel piping sump o diesel fill sump <br /> o dispenser 1/2 o dispenser 3/4 o dispenser 1/2 o dispenser 3/4 <br /> ❑ dispenser 5/6 o dispenser 7/8 o dispenser 5/6 ❑dispenser 7/8 <br /> o other: o other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST c 87-octane UST o 89-octane UST <br /> 0 91-octane UST o diesel UST ❑ 91-octane UST o diesel UST <br /> n other: ❑ other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> 0 87-octane UST o 89-octane UST o 87-octane UST ❑ 89-octane UST <br /> 0 91-octane UST o diesel UST o 91-octane UST ❑ diesel UST <br /> 0 other: o 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: ❑other: <br /> *This applies only if contractor has all required certifications. <br /> PR#: PE: 71 0 SC: 098 AcceAssigned To:pted To: Date: / <br /> ✓v <br /> EHD23- Rev.07/16/12 61 RETROFITV RIFI ION FORM <br />