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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 />Facility Trac 76 <br />Facility 2420 W Grant Line Road, Tracy, CA <br />Name: y <br />Address: <br />Facility Parveen Parashar <br />Tit1e: Manager <br />Contact: <br />class: A <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />Contractor Information <br />❑ 89 piping sump <br />Contractor Elite IV Contractors <br />Name: <br />❑ 91 piping sump <br />Contractor <br />Address: <br />2535 Wigwam Drive, Stockton, CA <br />g <br />License <br />Nu 1001331 <br />Number: <br />class: A <br />❑ dispenser 3/4 <br />contractor <br />Phone #: <br />(209) 461-6337 <br />Insurer: Markel Insurance Company <br />comersp.# <br />MWC0070230 <br />ICC Tech: Joe Bartholdi <br />Exp. Date: <br />8-5-16 <br />ICC Installer: Joe Bartholdi <br />❑ diesel UST <br />Exp. Date: <br />8-5-16 <br />Manufacturer <br />Training:Joe Bartholdi (BRAVO) <br />Model: <br />Exp. Date: <br />9-25-15 <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />D 91 -octane UST ❑ diesel UST <br />❑ other: <br />® Bravo float and chain replacement (JN,A 0 <br />Dispenser. Grade: uic'sc! <br />Dispenser: Grade: <br />Dispenser: Grade: <br />Dispenser: Grade: <br />"This applies only if contractor has all required certifications. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />n 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />Li other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />n diesel UST <br />❑ other: <br />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />other: <br />PR#: 0231580 PE: 23CL' SC: 098 Accepted By/ Elena Manzo Date: May 18, 2015 <br />Assigned To: <br />EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORA <br />