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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 /> FacilityMuni Service Cente Facility 1331 S. Har�l Ln. Lodi.. I_ 95240Name: Address: <br /> Facility <br /> Contact Pandy Laney Title: =1c i Services Supervisor <br /> Contractor Information <br /> Contractor IntractBagley Enterprises INC Addressor 2370 Maggio Circle ##4 Stockton, CA <br /> Name: <br /> CA License 774802 Class: C-C�'i (D-40;1 Contractor 909 333-6800 <br /> Number: Phone#: <br /> Insurer: Western Surety Company Workers' State Compensation; <br /> ICC Tech: Eric Mulgard Exp.Date: 2-12-15 <br /> ICC Installer: n/a Exp.Date: n/a <br /> Manufacturer yr Exp.Date: 10-2 7-14 <br /> Trainin <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: 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 /> ❑ 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 790091-001 SIV#098217 <br /> Dispenser: Grade: x87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST ❑diesel UST <br /> Dispenser: Grade: Xother "-1=lacsci external audible/Vi;ua <br /> 'This applies only if contractor has all required certifications. <br /> _ Accepted By! _,rl, Uy a. Date: <br /> PR#: PE: SC: Qg� Assigned To: p <br /> EHD 23 05 Rev.07!20/12 LIST RETROFIT VERIFICATION FORM <br />