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ENVIRON <br /> M TAL HEALTH DEARTMENT <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 /> y .. <br /> "heVrw. Fac�li 'Infosmat ons _ �-_: te r 3 F. <br /> Facility Facility ` / c� <br /> Name: <br /> Address: /q Y Y . ? . <br /> Facilityn r Title: <br /> Contact: l� <br /> ontractor.15formaton <br /> Contractor S'e r�i ee S -� S Contractor �jO v S 0 <br /> Name: Address: jj <br /> CA License Class: Contractor �rr� <br /> Number: T Phone#: ! / - 2 <br /> //�� Workers' <br /> 1) <br /> Insurer: S U rQ/1 Ce. do V-P � t f Comp.#: W"P 1- 5d 2 / <br /> ICC Tech: Wrcos Ke)(46e6 <br /> Exp.Date: I j L� ..17 <br /> ICC Installer: Exp. Date: n <br /> ManufacturerExp.Date: 12- 22 <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 detector replacement 19 Leak detector replacement Q nn 0141'Son S c*y- <br /> Model: Model: O`�9+3 40— q O.9 <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST X 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#: PE: SC: 098 Accepted By/ <br /> Q Assigned To: �t C�i Date: <br /> O � 1 <br /> EHD 23-05 Rev.07/16/12 UST RETROFIT VERIFICATION FORM <br />