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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 />Contractor <br />Service Station Sy stems <br />Contractor <br />680 Quinn Ave., San Jose, CA 95112 <br />Name: <br />❑ 87 fill sump <br />Address: <br />❑ 89 fill sump <br />License <br />485184 <br />Class: C-61 (D-40) <br />Contractor <br />(408) 213-6038 <br />Number: <br />Nu <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />Phone #: <br />Insurer: <br />ICW Groupworkers' <br />❑ 91 -octane UST <br />WPL502130700 <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />Comp. #: <br />❑ other: <br />ICC Tech: <br />Kris Bell <br />Exp. Date: <br />10-2-14 <br />ICC Installer: l Exp. Date: l <br />Exp. Date: <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Grade: west <br />Model: <br />Grade: west <br />❑ 87 piping sump <br />❑ 87 fill sump <br />1189 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 />❑ Leak detector replacement <br />Model: <br />❑ 91 -octane UST <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 />❑ 91 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />® Bravo float and chain replacement <br />Dispenser: 1/2 <br />Grade: west <br />Dispenser: 9/10 <br />Grade: west <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 />❑ 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 ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />PR#: 0231176 PE: 2361 SC: 098 Accepted By/ Garrett Backus Date: Dec 18, 2013 <br />Assigned To: <br />EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM <br />