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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 /> ;Information. <br /> Facility Facility <br /> Name: �_. i % ,> �f ( ti 1rz ,n, v �aGet � ' € f ! , :> Address. s"A �L I. � <br /> Facility n �5 <br /> Contact: Title: <br /> tlrrJntraCtOr.�h oftottOn r . x ., ' ... ., s ,.. ,. . i. . .f: ' ..�2'€�:t s_,z say;. .� >.c - <br /> r <br /> Contractor r ( r F Contractor <br /> r;� <br /> Name: l r t' t _ €rE F_ "i s € 1 ? ry i Address i ._ ! , <br /> Al _ <br /> CA Licenser r 4 + t Class: Contractor Phone # f "� V <br /> Number: cs� � <br /> t.!� r�- %` ; t ! <br /> Workers' ;, <br /> Insurer <br /> k '� <br /> .` lft`.{`' ' : Cu � . {7 �l 1 (� i Gr..,_/-i v ' ' • f Comp, <br /> E IGC Tech : rl t Exp. Date: t (r, r' r' 1 <br />- I -� <br /> ICC Installer. Exp. Date: // <br /> Traininacturer 1 � 0 �0 , i ` `1!) � . Exp. Date: ; > t ! :1 PIP <br /> ! [l <br /> Indicate below type of work to be performed . Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> ModeUt � � ;'} ' ` � s , r.- ' Model: <br /> Model : ( <br /> 0 87 piping sump o 87 fill sump o 87 piping sump ❑ 87 fill sump <br /> 0 89 piping sump ❑ 89 fill sump o 89 piping sump o 89 fill sump <br /> 0 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 /> o dispenser 1 /2 o dispenser 3/4 o dispenser 1 /2 o dispenser 3/4 <br /> o dispenser 5/6 o dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> Bother: `_ f o other: <br /> s <br /> ` t� " S <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model : Model : <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST o 89-octane UST <br /> 0 91 -octane UST ❑ diesel UST o 91 -octane UST o diesel UST <br /> ❑ other: ❑ other: <br /> ❑ Spill container replacement (not direct bury) ❑ Spill container replacement ( not direct bury) <br /> Model: Model : <br /> o 87-octane UST ❑ 89-octane UST o 87-octane UST ❑ 89-octane UST <br /> 0 91 -octane UST ❑ diesel UST o 91 -octane UST o diesel UST <br /> 0 other: ❑ other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG ) replacement <br /> Dispenser: Grade : Model : <br /> Dispenser: Grade : 0 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 91 -octane UST o diesel UST <br /> Dispenser: Grade. ❑ other: <br /> `This applies only if contractor has all required certifications. <br /> '[ERA: ,� ` I:. �. (_ 1 SC: 0`� $ Accepted By/ <br /> :Date: �. el, <br /> . <br /> PE. t { Assi ned To i ,, f - <br /> UST RETROFIT VERIFICATION FORM <br /> EHD 23.05 Rev. 07/16/12 <br />