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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 Trac Shell Name: y Facility 3:725 N. Trac Blvd., Trac Address: y y Facility Contact: MO1an Anvari Title: Operator Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 794380-208 ❑ 87 piping sump ❑ 87 fill sump Contractor Information ❑ 89 fill sump Contractor Name: Service Station Systems yems ❑ diesel piping sump Contractor Address: 680 Quinn Ave., San Jose, CA 95112 CA License Number: 485184 Class: C-61 ( D-40) Contractor Phone #: 408 213-6038 () Insurer: ICW Groupworkers' Comp. #: WPL502130700 ICC Tech: Steve Parmenter ❑ other: Exp. Date: Apr 15, 2013 ICC Installer: ❑ 87 -octane UST Exp. Date: ❑ 91 -octane UST Manufacturer Veede Training:r Root ❑ other: Exp. Date: Mar 1, 2014 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 794380-208 ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump x91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: Serial #972967 ❑ 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: ❑ 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#: 02314171 PE: 2361 SC: 098 I Accepted To/ Stacy Rivera I Date: Jan 29, 2013