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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Chevron #307709 Facility 10858 Trinity Pkwy., Stockton Name: Address: Facility Rosella Briggs gg Title: Manager Contact: Contractor Address: Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump Contractor Information ❑ 91 piping sump Contractor Name: Tanknology ❑ diesel fill sump Contractor Address: 11000 N. Mo Ex #500, Austin TX p ac p' CA License Number: 743160 Class: A vac sensor liquid float Contractor Phone #: 512 451-6334 ( ) Insurer: Great Divide Insurance Com anc p y ❑ 89 -octane UST workers Comp. #: WCA1920545 ICC Tech: Jarrod Cooke ❑ Spill container replacement (not direct bury) Exp. Date: Apr 30, 2015 ICC Installer: ❑ 89 -octane UST ❑ 91 -octane UST Exp. Date: ❑ other: Manufacturer Veeder Root Training: Exp. Date: May 7 2014 y ' Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 x other: S2 (87 vent) vac sensor liquid float ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ *This applies only if contractor has all required certifications. ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 89 piping sump ❑ 91 piping sump ❑ diesel piping sump ❑ dispenser 1/2 ❑ dispenser 5/6 ❑ other: ❑ 87 fill sump ❑ 89 fill sump ❑ 91 fill sump ❑ diesel fill sump ❑ dispenser 3/4 ❑ dispenser 7/8 ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: 0526212 PE: 2371 sC: 098 Accepted By/ Stacy Rivera Date: Apr 21 2014 Assigned To: y p ' EHD 23-05 Rev. 07/20/12