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1�1 1.1111111F <br /> 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 /> FaciRty Information <br /> Facility Vanco Truck-Auto Plaza Facility 1033 W. Charter Way, Stockton, CA 95206 <br /> Name: Address: <br /> Facility Mike Bo arai rue: Owner <br /> Contact: P <br /> contractor Information <br /> Contractor Elite IV Contractors Contractor <br /> NameAddress: 2535 Wigwam Dr., Stockton, CA 95205 <br /> : <br /> CA License Class: A-HAZ 1001331 Contractor ( )209 461-6337 <br /> Number: Phone#: <br /> Insurer: Midwest Employers Casualty Company wcoomrke.r#s: BNUWC0133392 <br /> ICC Tech: Fred Babel Exp.Date: Feb 20,2017 <br /> ICC Installer: Exp.Date: <br /> Than t"tOfer Veeder-Root Exp.Dale: Oct 1, 2016 <br /> T aini <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: VeederRoot 0794380-208(118293) Model: <br /> ❑87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> x91 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 /> ❑ dispenser 1/2 ❑dispenser 3/4 ❑ dispenser 1/2 ❑ dispenser 3/4 <br /> ❑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 c 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑diesel UST ❑ 91-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 /> PR#: PR0232352 PE 2361 SC: 098 AccepteBy/igned To: Fatinah Zareef Date: Jun 28, 2016 <br /> Ass <br /> EHD 2305 Rev.07/20112 UST RETROFIT VERIFICATION FORM <br />