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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 /> FacilityFood 4 Less Fuel Center Facility 3408 Manthe Road, Stockton, CA <br /> Name: Address: 3408 <br /> Facility er <br /> Jesus Jurado Title: Compliance Manager <br /> Contact: p g <br /> Contractor Information <br /> Contractor Service Station System, IContractor <br /> nc. Regional Parkway,Name: Address: g y'3224 Re tl Pkwa Santa Rosa, CA <br /> CA License 312844 Class: A Contractor <br /> Number: Phone#: <br /> Insurer: ACORD workers' <br /> Com .#: <br /> ICC Tech: Myke Briggs Exp.Date: Jun 11, 2017 <br /> ICC Installer: Exp.Date: <br /> Manufacturer Veeder Root Exp.Date: Dec 8, 2017 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: VR 794380-208 Model: <br /> ❑ 87 piping sump X87 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 /> ❑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 n diesel UST ❑ 91-octane UST o diesel UST <br /> Lj other: ❑other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> ,i87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> 0 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#: PE <br /> Accepted By/ Date: Dec 21, 2015 <br /> Ma)r/SZ f : ?G / SC: �9$ Assigned To: ? j, <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />