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ENVIRONMkTAL 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 /> � fnn <br /> formatio; 4 MEN : <br /> Facility t � Facility Q f C!M( Q <br /> Facility1,.�, `� Title: <br /> Contact: NA p &�C s v <br /> ►\ �� <br /> Contractor _ Contractor C � p <br /> Name: Address: J <br /> CA License Class: A/IContractor <br /> Number: Phone#: 1 <br /> Insurer: Workers' / <br /> Comp.#: <br /> ICC Tech: ® i 6 / Exp.Date: <br /> ICC Installer: Exp. Date: <br /> Manufacturer Exp.Date: <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: 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 /> ❑ 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 /> rA <br /> o surf�e c ' -+a, d tcsel -!�w - a►I <br /> *This applies only if contractor has all required certifications. S S fa q Hh't(a�--!''/I <br /> PR#: PE: 'j Accepted <br /> sC: 098 o: rlMe ! <br /> v Assigned To: W&M <br /> EHD 23-05 Rev.07/16/12 LIT <br /> RET I RIFICA I FOR <br />