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%wi <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 /> Facili Information <br /> FacilitNamey Safeway Fuel Center #1769 Faaless: 2808 Country Club Blvd., Stockton <br /> Facility Rob Singh Title: Safety & Environmental Affairs Manager <br /> Contact: g r 9 <br /> ontractorinfornation <br /> Contractor Service Station Systems Contractor 680 Quinn Ave., San Jose, CA 95112 <br /> Name: y Address: <br /> CA License 485184 class: contractor 408 971-2445 <br /> Number. Phone#: ( ) <br /> Insurer: Insurance Company of the West come n: WPL5021307 <br /> ICC Tech: Kristopher Bell Exp.Date: 09111/2016 <br /> ICC Installer: Exp.Date: <br /> Manufacture r Veeder Root Exp.Date: 11/18/2016 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: VR352 (SN#093091) Model: <br /> in 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump DK89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump <br /> ❑ 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: 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 ❑ 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#: 0516736 PE: 2361 SC: 098 Accepted By/ Stac Rivera Date: Jan 20, 2015 <br /> Assigned To: y <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />