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ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUNDSTORAGETANK w ��r 4 Facility tnforma%ion_ FacilityFacility Name: �` c Address: Contractor Facility I Title: Contract Contact: ❑ 87 piping sump Name: Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement ❑ Sensor replacement Contractor Model: Contract ❑ 87 piping sump Name: ❑ 87 piping sump ❑ 87 fill sump Addres .o s CA License ❑ 91 piping sump Class: ❑ 91 piping sump Contractor ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump Number: ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 1/2 Phone #: ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 Insurer:i ❑ other: Workers' j t ❑ Leak detector replacement Comp. #: ( _ ICC Tech: ❑ 87 -octane UST ❑ 89 -octane UST Exp. Date: ❑ 89 -octane UST ❑ 91 -octane UST ICC Installer:OWL;Exp. ❑ 91 -octane UST ❑ diesel UST Date: ❑ other: Manufacturer c6oe* P -S 00 C)V 6-058 6-8 Exp. Date: F-1Spillcontainer replacement �noat dire) bury) Trainin (not direct bury) Model: Model: Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement ❑ Sensor replacement Model: Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ other: Xt Leak detector repl ceme t ❑ Leak detector replacement Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: c6oe* P -S 00 C)V 6-058 6-8 F-1Spillcontainer replacement �noat dire) bury) ❑ Spill container replacement (not direct bury) Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement Dispenser: Grade: Model: Dispenser: Grade: ❑ 87 -octane UST ❑ 89 -octane UST Dispenser: Grade: ❑ 91 -octane UST ❑ diesel UST Dispenser: Grade: ❑ other: CA <441 *This applies only if contractor has all required certifications. PR#: 07/16/12 098 I Accepted By/ PE: SC: Assigned To: I t Date: LIST RETROFI VERIP k3