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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 <br />Cl <br />Facility v <br />Name: V <br />Address: Ct <br />Facility <br />Contact: <br />Title: <br />�n r <br />Indicate below type of work to be performed. Check all that apply. <br />Grade: _ <br />Contractor <br />Information <br />❑ sump <br />Contractor <br />Name: <br />rj L <br />�`" <br />Contractor <br />Address: <br />Z w !nn <br />< ' <br />CA License <br />Number: <br />��hh <br />V <br />❑ dispenser 3/4 <br />Class: R _I <br />Contractor <br />Phone #: <br />/ <br />Insurer:Workers <br />�X <br />V1 S <br />✓U Y' . <br />Comp. #: <br />P <br />ICC Tech: <br />�' <br />�� <br />Exp. Date: <br />ZS 2 <br />ICC Installer: <br />Exp. Date: <br />ManufacturerJ <br />A Z� <br />Exp. Date: <br />I <br />Training:b <br />�� <br />Indicate below type of work to be performed. Check all that apply. <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 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: _ <br />X-0. ensor replacement <br />odel: OR-(? �qd <br />87 fil <br />❑ 87 piping sump <br />❑ 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: Z <br />14 h V � <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 -octane 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 />❑ 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) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />Accepted PR#: �� I �O PE: 2 1 SC: 098 Ass gned To. <br />Datea i✓ f <br />EHD 23-05 Rev. 07/16/12 ST RETROFIT VE ONFORM <br />