Laserfiche WebLink
• 0 <br /> 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 Unocal 76 #255886 Facility 2701 March Lane, Stockton, CA 95219 <br /> Name: Address: <br /> Facility Darrell E ler Title: Manager <br /> Contact: <br /> PP <br /> Contractor Information <br /> Contractor Service Station S stems, Inc Contractor 680 Quinn Avenue, San Jose, CA 95112 <br /> Name: y Address: <br /> Nu License 312844 class: B,C-61(D-40) Phone#:or 408-213-6038 <br /> Number: <br /> Insurer: Insurance Company of the West Corr'kerss' WPL502190702 <br /> ICC Tech: Kris Bell Exp.Date: Sep 11, 2016 <br /> ICC Installer: Exp.Date: <br /> Manufacturer Bravo Exp.Date: Dec 5, 2017 <br /> Train ing: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> ❑87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump 1189 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 ❑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: 9/10 Grade: 87-octane 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#: 0231176 PE: 2300 sc: 098 Accepted By/Assigned To: Fatinah Zareef Date: Dec 10, 2015 <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />