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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 p /► Facility <br /> Name: Y ��1 Address: <br /> Facility <br /> Contact Title: <br /> Contractor Information <br /> ContractorContractor <br /> Name: Address: <br /> Na License Q Class: Contractor <br /> Number: �"6 Phone#: Z <br /> Insurer: Workers' <br /> Comp.#: <br /> ICC Tech: Exp. Date: C� <br /> ICC Installer: Exp. Date: <br /> Manufacturer <br /> Exp. Date: <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> VIDE prirc gvim w- V P30 If <br /> Sensor reace ent J El Sensor replacement <br /> Model: 0101?c ���" ���' Model: <br /> ❑ 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 /> 4 ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump <br /> Z G dispenser 1/2 Xdispenser 3/4 Z;qd31 ❑ dispenser 1/2 ❑ dispenser 3/4 <br /> ❑ dispenser 5/6 `<dispenser 7/8-25qD&3 ❑ 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: $`�_&L 00KA (2o0f <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#: <br /> C,-2-r37 6 S'6 P€3 5 l SC: 098 Accepted By/ —rm'n Date: Dp�� <br /> Assigned To: , ` <br /> EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM <br />