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ENVIRONMENTAL HEALTH DEPARTM <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton, Stockton, CA 95205-6232 FEB I 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> t' µ+.���y([�.�}��.ry[ `N'�}may }`�T e�(1��y T/jj K <br /> • V DE PG `OUND S i OR SME f A-"NK <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE'" <br /> ., •`tr-ff F ».'' J, Facility � ,• f ; ...� -,"f' <br /> Facility 1. ,y'r�} i 7^ "aj . ? 4t �ipV ./ Address; 1,1t"; ;'�'. ;' ` `• . <br /> Nam <br /> Facility �. .Title:. i,�.ta'i`'t:" �'{.t.'ytt,l�• .tM, = <br /> Contact d>; <br /> _ e�' b, cam o'�•t,# •... ,• <br /> Loontractor <br /> contractor i , : 'r;�•.;!, .} <br /> Name: r1f':%�- �'Z ;. Address: <br /> 1`. Contrae#t:ar 1,r)CA LicensClass: <br /> Number. s(it :1 t ,. Phone <br /> .^{ <br /> s`- <br /> Jorker3' �i.r }1.'l.r <br /> Insurer. f�Lj.jiK'� � y1 ', !r ; P 'I::•i f:+fit U Come, k rfvt. Ali. <br /> i /....•,.,. Exp.Cate:[CC Tach? <br /> icc Installer. Exp'Data' <br /> Manufacturer F,^,! ,:, v_-i �' FxP.Date: <br /> Tralnin '44 <br /> Indicate below type of work to-be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model:' Model: <br /> d 87 piping sump ❑87 fill sump ❑87 piping sump ❑ 87 fill sump <br /> a 89 piping sump r 89 fill sump ❑ 89 piping sump ❑89 fill sump <br /> ❑91 piping sump ❑91 fill sump o 91 piping sump a 91 fill sump <br /> a diesel piping sump a diesel fill sump a diesel piping sump a diesel fill sump , <br /> o dispenser 1/2 ❑dispenser 3/4 ❑dispenser 112 ❑dispenser 314 <br /> ❑dispenser 516 o dispenser 7/8 n dispenser 5/6 o dispenser 718 <br /> 0 other: <br /> In other. <br /> rNv Leak detector replacement [3 Leak detector replacement <br /> �'f :.'�S-zi :•z.j ,' Model: <br /> Model: ❑ 87-octane UST o 89-octane UST <br /> a 87-octane UST in 89-octane UST ❑ 91-octane UST a diesel UST <br /> �,a 91-octane UST ❑diesel UST <br /> cr ❑other: <br /> other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> ❑87-octane UST a 89-octane UST o 87-octane UST ❑ 89-octane UST <br /> a 91-octane UST o diesel UST o 91-octane UST o diesel UST..., <br /> o other: ca other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge(ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser. _ Grade: ❑87-octane UST a 89-octane UST <br /> Dispenser: Grade: a 91-octane UST ❑diesel UST <br /> Dispenser: <br /> Grade: ❑ other:. " <br /> * "his applies only if contractor has all required certifications. <br /> a; bp+ C 098 Accepted Bye },.'.,: ' � Date: <br /> PR#: ". t .•T 11 " !:J ";y( Assigned To: :t:. <br /> EHD 23-x. Rev,x7118/12 I.•. UST ROROFrr VERIFICATION ORM <br />