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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />$ <br />�.� .. itsmi ' Il. ' <br />Facility <br />Contact/1 <br />t `� K <br />. 1 ���_ 1j11 � <br />Contractor <br />Name <br />lal+-N <br />Dispenser: <br />Grade: <br />Contra or <br />OUR INA- <br />212 OZ CN4 <br />W 1 1M' WNWAMM <br />WA Phr- 141 <br />CA License" <br />number <br />❑ dispenser 1/2 <br />l <br />❑ dispenser 5/6 <br />Class <br />{ <br />ontractor <br />hone # <br />Model: <br />InsurerWork <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />CIOcomp. <br /># <br />Aina <br />ICC Tech <br />Model: <br />r( <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />Exp. Date <br />❑ diesel UST <br />❑ other: <br />ICC Installer <br />❑ Automatic tank gauge (ATG) replacement <br />rt <br />❑ 87 -octane UST <br />Exp. Date <br />Qom( <br />❑ diesel UST <br />Indicate below type of work to be performed. Check all that apply. 1 a <br />❑ Sensor replacement <br />►A0M <br />❑ 87 piping sump <br />❑ 89 piping sump <br />❑ 91 piping sump <br />❑ diesel piping sump <br />❑ dispenser 1/2 <br />❑ dispenser 5/6 <br />❑ other: <br />❑ 87 fill sump <br />❑ 89 fill sump <br />❑ 91 fill sump <br />❑ diesel fill sump <br />❑ dispenser 3/4 <br />❑ dispenser 7/8 <br />Leak detector replacement [ 6 Li I L <br />Model: I LO WW <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <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 <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />*This application applies only during routine inspections or monitoring certifications. <br />SR#: PE: 2308 sc: 098 Accepted By/ Date:/ <br />Assigned To: C <br />