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ENVIRONMATAL 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 />Facility(('' Facility rr <br />Name: -C Address: ".7 <br />Facility Title:o <br />Contact: t r <br />' <br />�-= <br />-- �Contractor';,_Information,,. <br />r <br />; <br />moi`- :`o- .-. <br />�,,�,�.�x�: .�.�:�- NOON <br />Contractor <br />Name: <br />- <br />(� �} 5 . {1 <br />Contractori <br />Address: <br />`i , <br />CA LicenseClass: <br />Number: <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />Contractor <br />Phone #: �� <br />`� <br />11 Co FJ -7 -7 <br />Insurer: <br />Q 1(� <br />Workers' <br />Comp. #: <br />jay\ <br />�YYN — l v lei eAIA Lie P.. -S <br />ICC Tech: <br />C p,�o CN <br />Exp. Date: <br />g _ CA �- 7 <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />ICC Installer: <br />Exp. Date: <br />❑ 89 -octane UST <br />Manufacturer <br />Manu <br />Manan <br />^ T <br />A AZ "�NAO(-, 7 �r7 je <br />Exp. Date: <br />i <br />_ 1 — <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />1187 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: 9 q L!P-- aoOv <br />❑ 87 -octane UST ❑ 89 -octane UST <br />X'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 />*This applies only if contractor has all required certifications. <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) <br />replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />Accepted By/ <br />PR#: PE: SC: 09$ Assigned To: <br />� � Lt a ✓"" Q�►�ll,�('� —i� �� Date: <br />EHD 23-05 Rev. 07/16/12 UST RETROFIT VERIFICATION FORM <br />13 <br />