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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 IMormation <br /> Facility United Gasoline Facility 3440 E Main Street, Stockton <br /> Name: Address: <br /> Facility Man reet Sin h Tide: Owner <br /> Contact: p 9 <br /> Contractor Information <br /> contractor David Wrinkler contractor 416 Second Street, Galt <br /> Name: Address: <br /> contractor <br /> CA Ucense 341375 Ciass: A Phone#: 2097440113 <br /> Number. <br /> Workers' <br /> Insurer. Comp.M <br /> [CC Tech: David Wrinkler Exp.Date: Mar 29, 2020 <br /> ICC Installer. Exp.Date: <br /> Manutaca'rer Veeder Root Exp.Date: 2/3/2018 <br /> Traini <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: 420 Model: <br /> 0 87 piping sump 0 87 fill sump 0 87 piping sump 0 87 fill sump <br /> 0 89 piping sump 0 89 fill sump 0 89 piping sump ❑89 fill sump <br /> 0 91 piping sump 0 91 fill sump 0 91 piping sump 0 91 fill sump <br /> 0 diesel piping sump 0 diesel fill sump 0 diesel piping sump 0 diesel fill sump <br /> ❑dispenser 1/2 0 dispenser 3/4 ❑dispenser 1/2 0 dispenser 3/4 <br /> 0 dispenser 5/6 c dispenser 7/8 ❑dispenser 5/6 0 dispenser 7/8 <br /> tgother: 91 Annular 0 other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑87-octane UST ❑ 89-octane UST 0 87-octane UST 0 89-octane UST <br /> ❑ 91-octane UST 0 diesel UST 0 91-octane UST 0 diesel UST <br /> 0 other: ❑other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> 0 87-octane UST 0 89-octane UST 0 87-octane UST 0 89-octane UST <br /> 0 91-octane UST 0 diesel UST 0 91-octane UST 0 diesel UST <br /> 0 other: ❑other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: 0 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: 0 91-octane UST 0 diesel UST <br /> Dispenser: Grade: 0 other: <br /> "This applies only if contractor has all required certifications. <br /> PR#: 0231173 PE: SC: 098 Accepted By/ Date <br /> Assigned To: <br /> EHD 2305 Rev.07/20/12 UST RETROFIT VERIFICATIO ORM <br />