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0 40 <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 /> Fadlity Fast Lane Central Valley LLC Facility 116 Roth Road Lathrop, CA <br /> Name: Address: <br /> Facility Agnes Mabalot Title: Manager <br /> er <br /> 9 <br /> Contractor Information <br /> Contractor EPIC Environmental Compliance System Address:Contractor <br /> rn <br /> Name: p 39120 Argonaut Way#643, Fremont, CA <br /> License 956593 Class: A contractor <br /> Nu 888-700-EPIC <br /> Number: Phone#: <br /> Insurer: American Contractors Indemnity Co. Workers' 1850635 <br /> Comp.#: <br /> ICC Tech: Alvin Milburn Exp.date: February 14, 2017 <br /> ICC Installer: Exp,Date: <br /> Manufacturer Veede <br /> Training: r Root Exp.Date: July 12, 2017 <br /> Indicate below type of work to be performed. Check all that apply. <br /> N Sensor replacement ❑ Sensor replacement <br /> Model: 0794380-208 Model: 0794380-208 <br /> ❑ 87 piping sump ❑ 87 fill sump n 87 piping sump ❑ 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 /> xdiesel piping sump ❑ diesel fill sump xdiesel piping sump ❑diesel fill sump <br /> ❑ dispenser 1/2 ❑dispenser 314 ❑ dispenser 112 ❑ dispenser 314 <br /> ❑dispenser 516 ❑ dispenser 718 ❑ dispenser 516 ❑ dispenser 718 <br /> ❑ other: Diesel North STP Sump ❑ other: Diesel South STP Sump <br /> ❑ Leak detector replacement ❑ Leak detector replacement <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 /> ❑ 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 o 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#: 0523684P�: 2351 se: 098 Accepted By date: 06/17/2016 <br /> Assigned To <br /> EHD 23-05 Rev.07120112 UST RETROFIT VERIFICATION FORM <br />