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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 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Facility �r Name: Address: Facility - Title: Contact: Contractor Information Contractor Contractor. 51 6 Name: 1 Address: V CA License Class: Contractor �5 Number: Phone#: Workers' Insurer: Urjkomp ICC Tech: ld) Exp. Date: –zb l ICC Installer: Exp. Date: `T Manufacturer Exp. Date: Training: Indicate below type of work to be performed. Check all that apply. Z Sensor replacement 1 ❑ Sensor replacement Model: I Model: ❑ 87 pipi sump ❑ T7 fill sump ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other.` � f❑ other: ❑ Leak detector replacement ❑ Leak detector replacement Model: Model: ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Spill container replacement (not direct bury) ❑ Spill container replacement(not direct bury) Model: Model: ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement Dispenser: Grade: Model: Dispenser: Grade: ❑ 87-octane UST ❑ 89-octane UST Dispenser: Grade: ❑ 91-octane UST ❑ diesel UST Dispenser: Grade: ❑ other: *This applies only if contractor has all required certifications. PR#: V 3J-76% PE: SC: 098 Accepted By/ J Date: I u, Assigned To: 032% EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM