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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 /> Facy Arco Am Pm 83333 Facility 550 W. Val ico Road, Trac <br /> Name: Address: p y <br /> Facility Edgar Rizkallah Title: Owner <br /> Contact: 9 <br /> Contractor Information <br /> Contractor Guadalupe Sanchez Contractor 3619 Kin Court <br /> Name: Address: g <br /> CA License C61/D40A class: A Contractor 925-470-0803 <br /> Number: Phone#: <br /> Insurer: Acord 35076 workers' 9214798-17 <br /> Comp.#: <br /> ICC Tech: #5250451 Exp.Date: 4-8-2019 <br /> ICC Installer: #5250451 Exp.Date: 12-29-2018 <br /> Manufacturer Veeder-Root Exp.Date: 11-2-2017 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: (serial 1236540) -- 304 Brine sensor Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump X87 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 xdispenser 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 ❑ 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#: PR0536555 PE: 2351 SC: 098 Accepted By/ FDate: 10-25-2017 <br /> Assigned T <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />