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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 /> r <br /> " Facile Information:` __ '�' ` <br /> Facility M �� f Facility j�,/� /] �s / <br /> Name: ►"r✓1 Q / Address: I"l / <br /> Facility f/�� Title: <br /> Contact: v' <br /> �},�.�/ -4-M <br /> /�� " �. ` ,,� �^�� � <br /> Contractor Contractor 16� ��51 r ^f v(/f �GkY� %67 7d <br /> Name: Address: <br /> CA License J� /� Class: ContractPhone#or l / <br /> Number: Workers' <br /> Insurer: <br /> Insurer: AA �k , 6r?� eh Com #: 4 �00 <br /> J <br /> ICC Tech: / ` f7a vO„-, Exp. Date: • f <br /> ICC Installer: Exp. Date: <br /> Manufacturer �/lc r� 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 detecto replacement El Leak detector replacement <br /> Model: ✓lR !i3e eq"X 55bggj Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> X91-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 /> *This applies only if contractor has all required certifications. <br /> PR#: ba3 L ' PE: SC: O9H A s gned To: a Date: <br /> EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM <br />