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0 0 <br /> ENVIRONMENTAL <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUNDSTORAGETANK <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br /> Fac4ftylaWm0w <br /> Facility Facility <br /> Name: Vi Address: t tZ Lot) <br /> Facility <br /> Contact: EQ.s Title: <br /> ctaritnfonhaftn <br /> Contractor ® Contractor ,�p <br /> Name: Address: <br /> CA License �U Contractor <br /> Number: Class: 'f 1 1 <br /> Phone*: G®�t®t i <br /> Insurer:�,. Ln_j NjV Q ce ComWorke#: CA 1000 o4V"t S ' <br /> ICC Tech: 'CC SCQv4C .rf; Exp.Date: (•Z ®+,71 <br /> ICC Installer. icc tN O. <br /> �� Exp.Date: „ ' <br /> Manufacturer . <br /> Train Exp.Date: Z-Z?.• I`� <br /> Indicate below type of work to be performed. Check all that apply. <br /> ensor replacement ❑ Sensor replacement <br /> Model: f 350-12 odel: <br /> ❑87 piping sump QC87 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 /> V ❑dispenser 1/2 ❑dispenser 3/4 ❑dispenser 1/2 ❑dispenser 3/4 <br /> �j ❑dispenser 5/6 ❑dispenser 7/8 ❑dispenser 5/6 ❑dispenser 7/8 <br /> ❑other: ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑87-octane UST ❑89-octane UST ❑87-octane UST ❑89-octane UST <br /> ❑ 91-octane UST ❑diesel UST 1191-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 /> Accepted By/ <br /> PR# ``°'11� PE: SC: 09$ Assigned To: Date: S !3 <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />