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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 UNDERGROUNDSTORAGETANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility fi Facility Name: Address: Facility Contact: Ll Title: %✓ Indicate below type of work to be performed. Check all that apply. Grade: _ Contractor Information Model: ,2..0,9 Contractorj Name: i / --� l ,f 4 L� IV C04r,rL Q-• 1187 fill sump Contractor Address: �3 CA License(Class: Number: ❑ iesel piping sump Contractor Phone #: (0�[ Insurer: /Y) Prlw1 . .Z A ❑ dispenser 7/8 Workers' ^ Comp. #: ❑ 89 -octane UST ICC Tech: CJ ❑ other: Exp. Date: ❑ Spill container replacement (not direct bury) ICC Installer: �dS ❑ 87 -octane UST Exp. Date: ❑ 91 -octane UST Manufactureri , Training: � R- -2/1- 1 ❑ other: Exp. Date: �- -.2 % Indicate below type of work to be performed. Check all that apply. ❑ 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 ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ fXSensor replacement W9/83_72 Model: ,2..0,9 Grade: _ ❑ 87 piping sump 1187 fill sump ❑ 89 piping sump ❑ 89 fill sump 91 piping sump ❑ 91 fill sump ❑ iesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ 89 -octane UST ❑ 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 ❑ 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 1191 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: ❑ 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 ❑ 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#: pQ i go 1 D PE: 6 %0 I SC: 098 Accepted o: I r /az,.)L. Date: 6-1.8-2-0 /.8 - r� � �w ✓ Assigned To: / .Ls� EHD 23-05 Rev. 07/16/12 UST RETROFIT VERIFICATION FORM