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ENVIRONMONTAL HEALTH DEWRTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* -= Indicate -ContractorinformationY� ,'Y �Facili information '_ W r w Facility A A - + ,� ❑ diesel piping sump Facility fbl V& Name: F�{',(,�1,(co"a a2 Address: -A 9-- Facility JI /1 „�j IA Insurer: Title: (�/rs Contact: (V `(.tom( i �( �� p � � F �� , ( Ptf �- 5 ' l.L� - ICC Tech: ❑ Spill container replacement (not direct bury) Model: Exp. Date: -j'/ ICC Installer: cuu+ ❑ diesel UST ❑ other: -= Indicate -ContractorinformationY� ,. p_ Contractorontractor Name: ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump Address: 3 q ov = , r� , 0j, Sc o. CA License Number: 6 F3 a2 Class: -A 9-- Contractor Phone #:g Model: Insurer: �"p� 9& (�/rs 171 Y1' orkers' om . #: �� p � � F �� , ( Ptf �- 5 ' l.L� - ICC Tech: ❑ Spill container replacement (not direct bury) Model: Exp. Date: -j'/ ICC Installer: cuu+ ❑ diesel UST ❑ other: Exp. Date: - 2� - Manufacturer #CL/VVLL1 Exp. Date: ^ -f-15-2-0K- f- -20K- Training:M ❑ diesel UST Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: Leak detector replacement OL ModeI1L-0-iQcx2 4 1 —10Y 446 3 )(87 -octane UST ❑ 89-octane(UST ❑ 91 -octane U,9Tiidiesel UST ❑ other: UV -D- ilk l yt Q ~ ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ *This applies only if contractor has all required certifications. ❑ Sensor replacement Model: [:187 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: �Va�l /'q I PE: �/_ I SC: 098 Accepted o: 0�� A Date: �? V 1O Assigned To: , �✓ EHD 23-05 Rev. 07/16/12 UST RETROFIT VERIFICATION FORM