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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN CO'JNTY RECEIVED <br />1868 E. Hazelton, Stockton, CA 95205-6232 <br />Telephone-. (209) 468-3420 Fax: 209) 468-3433 APR 1512014 <br />UNDERGROUND STORAGE TANK ENVIRONMENTAL HEALTH <br />RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* DEPARTMENT <br />Contractor lnfoiiiiiWart . . .......... <br />Contractor I <br />Elite"IV Contractors <br />FacilityFablity <br />Waterloo Foodmart <br />4" 15 E. Waterloo. Rd., Stockton <br />Name <br />Address: <br />Facility Bill Sodhi <br />ta <br />Contact <br />-- <br />Insurer: State Compensation Insurance Fund <br />Title: Cli vner <br />Contractor lnfoiiiiiWart . . .......... <br />Contractor I <br />Elite"IV Contractors <br />"Ontractof :1-53,-) VMgvvarn Dr., Stockton, CA 952013 <br />Name: <br />dress, <br />CA Ucense 660076 Class: A <br />Number... I <br />,,Ad <br />Contract or 6 3, 3 <br />Phorie # (20'-­%� 461 <br />-- <br />Insurer: State Compensation Insurance Fund <br />v'o*"" 11084625 <br />c dispenser 3/4 <br />* dispenser 5/6 1 <br />JCC Tech: Joseph Barthuldi <br />Exp. Date: Jul 12, 2014 <br />icc installer: <br />Exp. Date, <br />,Gnu""' Veeder Root <br />Exp. Date: , fpr 28, 20115 <br />Training.,- ____ <br />* other: <br />Indicate Wow type of work to be performed. Check ali that apply, <br />2 Sensor replacement <br />Model: Feeder Root 304 <br />11 87 piping sump <br />o 87 fill sump <br />:1 89 piping sump <br />3 89 fill sump <br />91 piping sump <br />0 91 fill sump <br />diesel piping sump <br />o diesel fill sump <br />* dispenser 1/2 <br />c dispenser 3/4 <br />* dispenser 5/6 1 <br />o dispenser 7/8 <br />xother: 87 fid suinp annular <br />0 Sen ior replacement <br />MEM <br />-- <br />87 piping sump <br />o 87 fill sump <br />:j 83 piping sump <br />0 89 fill sump <br />n 91 piping sump <br />"- 91 fill sump <br />:3 d esel piping sump <br />rj diesel fill sump <br />-- o spenser 1/2 <br />n dispenser 314 <br />* d spenser 5/6 <br />c dispenser 718 <br />* c Cher <br />Mo Jel: <br />ci 87 -octane LIST o 89 -octane UST <br />El Leak detector replacement <br />0 Leai; detector replacement <br />Model: <br />Mo Jel'. <br />o 87 -octane LIST a 89 -octane UST <br />8 7 -octane LIST x:189 -octane UST <br />ci 91 -octane LIST Li diesel LIST <br />91 -octane LIST o diesel LIST <br />a other'. <br />ether. <br />F-1 Spill container replacement (not direct bury) <br />1771 Spil container replacement (not direct bury) <br />Model: <br />Mo Jel: <br />ci 87 -octane LIST o 89 -octane UST <br />8 7 -octane LIST c 89 -octane UST <br />* 91 -octane LIST n diesel UST <br />91 -octane U ST ri diesel LIST <br />* other: <br />c:her: <br />F Bravo float and chain replacement <br />0 Autc matic tank gauge (ATG) replacement <br />Dispenser: Grade: <br />Mo lel: <br />Dispenser: Grade: <br />c 87 -octane LIST o 89 -octane LIST <br />Dispenser: Grade.- <br />❑ 91 -octane LIST o diesel LIST <br />Dispenser: Grade: <br />a other: <br />*This applies only if contractor has all required Oertificatiorls. <br />PFZ#: 0231760 <br />_I <br />PE 2351 <br />1. 1. <br />SC: 098 Accepted Byl <br />Assigned To. Stacy Rivi-."I"a <br />Date: Apr,3 2014. <br />I <br />EHO 23-05 Rev. 070OV12 <br />— <br />UST RETROFIT —VERIFJCATFON —FORM <br />