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ENVIRONM&TAL HEALTH DEI-ARTMENT <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 /> FacilityC 1 a Facility _ <br /> Name: o b o 8 6 Address: S r✓ LoV <br /> Facility �� 1 , o + Title: n <br /> Contact: Kare,, vV <br /> Contractor Information <br /> Contractor Contractor / dd <br /> Name: Ge W1 e 4-- Address: (�O S c�, r f�� <br /> CA License j¢qz A Contractor Q <br /> Number: ZZO Class: Phone#: 7 5 �� <br /> Insurer: Workers' <br /> Comp.#: ;2- <br /> ICC <br /> 2ICC Tech: f. rL Exp.Date: <br /> ICC Installer: ? ja CIL <br /> Exp. Date: 3 <br /> Manufacturer Exp. Date: <br /> er -3Trainin : P 1 <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement _'Ser- iaI t£ I ) t,4 &8z ❑ Sensor replacement <br /> Model: Ve(&j ur Roe t 629,13 8 6 - 2 08 Model: <br /> ❑ 87 piping sump X'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 /> ❑ 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 /> ❑ 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 /> PR#: / PE: SC: 098 Accepte By/ DatepZ O <br /> Assigned T ' 0761 < <,� <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />