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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,"Iffzj <br />' <br />Facility1,Name: <br />"{ <br />Grade: _ <br />Contractor <br />Name: N�L <br />Address: Wj <br />Contractor <br />Address: <br />Facility <br />Title: <br />Contact: <br />Class: /� <br />P v1O� v <br />Indicate below type of work to be performed. Check all that apply. <br />Sensor rept m� n,t <br />V� <br />Model: l U / <br />❑ 87 piping sump ❑ 87 fill sump <br />❑ 89 piping sump ❑ 89 fill sump <br />❑ 91 piping sump ❑ 91 fill sump <br />❑ diesel piping sump ❑ diesel fill sump <br />❑ dispenser 1/2 ❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />X <br />❑ dispenser 7/8 <br />other: Q�E�'!�!'lA.,lgLrSrlif� <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87-oct2ne UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Contractor <br />Information <br />Grade: _ <br />Contractor <br />Name: N�L <br />SfS <br />Contractor <br />Address: <br />/ J <br />CA License (�('' <br />Number: 0 J <br />❑ dispenser 3/4 <br />Class: /� <br />P v1O� v <br />Contractor <br />Phone #: <br />�J <br />b 17/ <br />Insurer: <br />���� // <br />lN�� <br />Workers' <br />Comp. #: <br />,t <br />v <br />ICC Tech: a <br />❑ 87 -octane UST <br />Exp. Date: <br />❑ 91 -octane UST <br />ICC Installer: <br />❑ other: <br />Exp. Date: <br />❑ Spill container replacement (not direct bury) <br />Manufacturer <br />Training: <br />Exp. Date: <br />I <br />Indicate below type of work to be performed. Check all that apply. <br />Sensor rept m� n,t <br />V� <br />Model: l U / <br />❑ 87 piping sump ❑ 87 fill sump <br />❑ 89 piping sump ❑ 89 fill sump <br />❑ 91 piping sump ❑ 91 fill sump <br />❑ diesel piping sump ❑ diesel fill sump <br />❑ dispenser 1/2 ❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />X <br />❑ dispenser 7/8 <br />other: Q�E�'!�!'lA.,lgLrSrlif� <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87-oct2ne UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />*This applies only if contractor has all required certifications. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge (ATG) <br />replacement <br />Model: <br />_ <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#:O Z�3 jc / PE: -Z 3 % SC: �9$ Accepted o: UP))) f�� 1`6 Date: <br />`7`- / Assigned To: f}'1� <br />EHD 23-05 Rev. 07/16/12 11 UST RETROFIT VERIFICATION FORM <br />0 <br />