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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Waterloo Foodmart Name: Facility 4315 E. Waterloo Rd., Stockton Address: Facility Bill Sodhi Contact: Title: Owner Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 304 ❑ 87 piping sump Contractor Information ❑ 89 piping sump Contractor Name: Elite IV Contractors Contractor Address: g 2535 Wigwam Dr., Stockton, CA 95205 CA Number: 660076 class: A Contract Phone #�r (209) 461-6337 Insurer: State Compensation Insurance Fund P Workers' Comp. #: 9084625 ICC Tech: Joseph Bartholdi Exp. Date: Jul 12, 2014 ICC Installer: u other: Exp. Date: ❑ Spill container replacement (not direct bury) Manufacturer Veeder Training:Root Exp. Date: Apr 28, 2015 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 304 ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 xother: 87 fill sump annular ❑ Leak detector replacement ❑ Leak detector replacement Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST u other: ❑ other: ❑ Spill container replacement (not direct bury) Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ "This applies only if contractor has all required certifications. ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: 0231760I PE: 2351 sc: pgg Accepted By/ StacyRivera Date: Apr 3, 2014 Assigned To: p