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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 Information <br /> re <br /> Atldss <br /> March and Bianchi Chevron Facilityy <br /> N. 1916 E March Lane, Stockton <br /> Name: : <br /> Facility Jeet Kaur Title: Manager <br /> Contac: g <br /> Contractor Information <br /> c tactor Mid Valley Consulting Adtl�dor 1097 Bronco Drive, Plumas Lake, CA <br /> Name: <br /> CA uCe""' 920985 class: A contractor 530-749-9892 <br /> Number: Phone is <br /> Insurer. <br /> Mid Century Insurance c=",. A09468650 <br /> Icc Tech: Jason Haase Exp.Date: 7-1-16 <br /> ICC Installer: Jason Haase Ems.Date: 7-1-16 <br /> Jason Haase Exp Date: VR: 12-11-2015 <br /> Train <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: 79430-304# 1046363 Model: <br /> n 87 piping sump o 87 fill sump o 87 piping sump o 87 fill sump <br /> n 89 piping sump o 89 fill sump o 89 piping sump o 89 fill sump <br /> 0 91 piping sump o 91 fill sump o 91 piping sump n 91 fill sump <br /> o diesel piping sump o diesel fill sump o diesel piping sump In diesel fill sump <br /> Xclispenser 1/2 o dispenser 3/4 o dispenser 1/2 o dispenser 3/4 <br /> o dispenser 5/6 n dispenser 7/8 o dispenser 5/6 o dispenser 7/8 <br /> 0 other: c other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> 0 87-octane UST o 89-octane UST o 87-octane UST o 89-octane UST <br /> 0 91-octane UST o diesel UST o 91-octane UST o diesel UST <br /> 0 other: u other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> 0 87-octane UST o 89-octane UST o 87-octane UST o 89-octane UST <br /> n 91-octane UST o diesel UST o 91-octane UST ❑ diesel UST <br /> 0 other: o other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge(ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: n 87-octane UST o 89-octane UST <br /> Dispenser: Grade: 0 91-octane UST o diesel UST <br /> Dispenser: Grade: o other: <br /> 'This applies only if contractor has all required certifications. <br /> PR#: 0527728 PE: 2352 se: 098 Accepted By/Assigned To: Elena Manzo Date: Nov 18, 2014 <br /> EHD 23-05 Rw.07/20112 UST RETROFIT VERIFICATION FORM <br />