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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 It <br /> Facility ++ -- Facility <br /> Name: K Address: <br /> Facility Title: <br /> Contact: YVI n'1l <br /> Contractor Information <br /> Contractor / ContractorW <br /> Name: eb,t( !� Address: -t)15 V t1 UW► <br /> CA License � 2 Class: Contractor , <br /> Number: J Phone#: <br /> Workers' <br /> Insurer: �� T-in Comp.#: <br /> ICC Tech: Y e)agCX Exp. Date: a •X0- <br /> ICC Installer: Exp. Date: �• i"� <br /> Manufacturer , A _ , <br /> Training: (��l Exp. Date: VP_: 0- (— (jc:> <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement ElSensor replacement <br /> n <br /> Model: _0 1 — # `1 g 9 c o Model: <br /> 'pd,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 /> c 87-octane UST i-i 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: <br /> Dispenser: Grade: ❑ 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST _ diesel UST <br /> Dispenser: Grade: ❑other: <br /> "This applies only if contractor has all required certifications. <br /> i nno Accepted By/ <br /> ��. �5 I y 5 3 ,- ')L- I , �-W <br />