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ENVIRONMENTAL HEALTH DEARTMENT <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 />Contractor <br />SERVICE STATION SYSTEMS, INC. <br />contractor <br />680 QUINN AVE., SAN JOSE, CA 95112 <br />Name: <br />Address: <br />CA License <br />485184 <br />class: B, C61 /D40 <br />Phone # r <br />408-213-6038 <br />Number: <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />Insurer: <br />INSURANCE CO. OF THE WEST <br />workers' <br />WPL502190702 <br />❑ diesel piping sump <br />❑ diesel fill sump <br />Comp. #: <br />❑ dispenser 3/4 <br />ICC Tech: <br />KRISTOPHER BELL <br />Exp. Date: <br />09/11/2016 <br />ICC Installer: <br />❑ dispenser 7/8 <br />Exp. Date: <br />❑ other: <br />Manufacturer <br />VEEDER ROOT <br />Exp. Date: <br />05/11/2017 <br />Trainina: <br />❑ Leak detector replacement <br />❑ Leak detector replacement <br />_ <br />Indicate below type of work to be performed. Check all that apply <br />® Sensor replacement <br />❑ Sensor replacement <br />Model: 794380-208 <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />xdiesel piping sump <br />❑ diesel fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />(other: REPLACED DIESEL STP RELAYo <br />❑ other: <br />'2e4 Jct c k,_t <br />'PR b -7 A GO -- J2 0 <br />k> <br />❑ Leak detector replacement <br />❑ Leak detector replacement <br />Model: <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />❑ Spill container replacement (not direct bury) <br />Model: <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Bravo float and chain replacement <br />❑ Automatic tank gauge (ATG) replacement <br />Dispenser: <br />Grade: <br />Model: <br />Dispenser: <br />Grade: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />Dispenser: <br />Grade: <br />❑ 91 -octane UST <br />❑ diesel UST <br />Dispenser: <br />Grade: <br />❑ other: <br />*This applies only if contractor has all required certifications. <br />PR#: PR0231417 I PE: 2361 I SC: 098 Accepted By/ VICKI MCCARTNEY Date: 01/27/2016 <br />Assigned To: <br />EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM <br />