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ENVIRONMENTAL HEALTH DEPARTMPH! <br /> C Fj V <br /> E,-_�` D <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 Telephone: NOV 0 2 2016 <br /> (209) 468-3420 Fax: (209)468-3433 <br /> UNDERGROUND STORAGETANK ENVIRONMENTAL HEALTH <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* DEPARTMENT <br /> Facility Information <br /> Facility .i tr 0-,,,. LLC Facility 116 E Roth Read, Lathrop, CA <br /> Name: Address: <br /> Facility Agnes Mabalot Title: Manager <br /> Contact: g <br /> Contractor Information <br /> Contractor EPIC Environmental Compliance Syster-,_ Contractor :39120 Argonaut Way#643, Fremont, CA <br /> Name: Address: <br /> CA License ; E6593 Class: A Contractor 388-700-EPIC <br /> Number. Phone: <br /> Insurer 'i,:yCo. Workers' 1850635 <br /> Comp.#: <br /> ICC Tech Alvin Milburn Exp. Date: February 14 2017 <br /> ICC Installer Exp. Date: <br /> Manufacturer , eeder Rant Exp. Date: ,July 12 2017 <br /> Training <br /> Indicate below type of work to be performed. Check all that apply. <br /> E-1 Sensor replacement Z Sensor replacement <br /> Model ' - Model: <br /> ❑ 87 piping sump L) 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump J 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump _j 91 fill sump <br /> Z diesel piping sump ❑ diesel fill sump 21 diesel piping sump ❑ diesel fill sump <br /> dispenser 112 ❑ dispenser 314 ❑ dispenser 112 LJ dispenser 314 <br /> ❑ dispenser 516 U dispenser 718 ❑ dispenser 5/6 ❑ dispenser 718 <br /> ❑ other: Diesel North STP Su z u ❑ other: Die:,,el South STP S, <br /> i in <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST LJ 89-octane UST <br /> IJ91-octane UST ❑ diesel UST ,.,I 91-octane UST Ll diesel UST <br /> J other: <br /> ❑ other: <br /> ❑ Spill containerreplacement(notdirectbury) ❑ Spill container replacement(notdirectbury) <br /> Model: Model: <br /> LJ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST LI diesel UST ❑ 91-octane UST ❑ diesel UST <br /> LJ other: ❑ other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: ❑ 87-octane UST C] 89-octane UST <br /> Dispenser: Grade: Cl 91-octane UST ❑ diesel UST <br /> Dispenser: Grade: ❑ other: <br /> *T1iis applies only if contractor has all required certiflCaticros. <br /> PR#: 5„ 8, IJ1. se: 09$ <br /> Accepted By/ � Date: 06/17/2016 <br /> I� '�'� Assl ned To- <br /> ENI7 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION 1-010,1 <br />