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ENVIROWL-ITAL HEALTH DEI.�RTMENT 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 ❑ 87 fill sump Facility1 L L ( Name: % «5 �{ CJ S L % G �f Facility Address: 7' 7 �` L" b�, ✓ d / �'ti c-, LOW, Facility ((1If Contact: l� Gf V .� I M Title: man Indicate below type of work to be performed. Check all that apply. B Sensor replacement ❑ 87 fill sump Contractor Information ❑ 87 piping sump Contractor Name: < S � Y S- (.4 Std iYi J Contractor Address: Q u -T /VIJ /VIiq vz _ S / jos CA License Number: (� Ci �' Class: C (,I i✓ Contractor Phone #: - Z - Insurer: ,r F ,Id ,C VV i ) E S Workers' Comp. #: W, ? L b Z 19 () ICC Tech: t S ❑ other: Exp. Date: 4 G ICC Installer: ❑ 87 -octane UST Exp. Date: ❑ 91 -octane UST Manufacturer Training: IE E D iv A il`C � T Exp. Date: 3 Indicate below type of work to be performed. Check all that apply. B Sensor replacement ❑ 87 fill sump Model: "% X43 6 CJ - 2 ❑ 87 piping sump Z 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: Model: ❑ 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 ❑ 91 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: Accepted By/ ` / /�n /, ., PR#: D 2 3 ! 9 4.69 PE: 3 G ( SC: X98 Assigned To: V I j I r e_ „/ Ili, �/ Date: � /�w 11'7 EHD 23-05 Rev. 07/20/12 U T RETROFIT RIFT ATION FORM