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0 '0111 <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 /> Facility Information <br /> Facility Arch Arco AM PM nae ss: 4855 S. Hwy 99, Stockton <br /> Name: <br /> Facility Jivtesh Gill Title: Owner <br /> Contact: <br /> Contractor Information <br /> Contractor Reliable Petroleum Contractor <br /> ddie s <br /> Name: : 11930 Horseshoe Rd., Oakdale <br /> CA License 883706 class: A Phone#°` (209) 845-8586 <br /> Number: <br /> Insurer: State Compensation Insurance Fund Comerp.s: 9045958 <br /> Cc Tech: Guadalupe Sanchez Exp.Date: Apr 20, 2015 <br /> ICC Installer: Exp.Date: <br /> Ma"ufacturerVMl Installer Exp.Date: May 12, 2015 <br /> Trainin <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> n 87 piping sump o 87 fill sump ❑ 87 piping sump n 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 /> n 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:VMI LD 99-2000 SN: 13101004 Model: <br /> ❑87-octane UST X 89-octane UST ❑87-octane UST ❑89-octane UST <br /> ❑ 91-octane UST n 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 o 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST o diesel UST <br /> ❑ other: ❑ other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: D 87-octane UST o 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#: 0506650 PE: 2361 SC: 098 A gnetl Boled To: y Stac Rivera Date: Nov 19, 2013 <br /> Assi n <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />