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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 ARCO 06080 Facility 85 E LOUISE AVE LATHROP, CA 95330 <br /> Name: Address: <br /> Facility Terri Mala Title: Facility manager <br /> Contact: Y Y 9 <br /> Contractor Information <br /> Contractor Gettler Ryan Contractor 6805 SIERRA CT STE G DUBLIN, CA 945 <br /> Name: y Address: <br /> CA License 220793 class: q Contractor 925 551-7555 <br /> Number: Phone#: ( ) <br /> Insurer: XL SPECIALTY INSURANCE COMPANY WorkersUB7K6098961826G <br /> Comp.#: <br /> ICC Tech: David Rouse Exp.Date: 6-28-20 <br /> ICC Installer: Exp.Date: <br /> Manufacturer <br /> Training: Veeder Root Exp.Date: 7-2-20 <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: Veeder Root 330020-464 Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 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 /> ❑ 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 /> xother: S10 smart sensor vapor in 87 STfa ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-oct2ne 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#:��o a PE: 2351 SC: 098 Accepted By/ Elena Manzo Date: Jan 22, 2019 <br /> Assigned To: <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />