Laserfiche WebLink
ENVIRONMATAL 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 />Facieinformation <br />Facility505 N Main Street, Manteca <br />Quick Stop Market #5124 Address: <br />Facility. Satwinder Singh <br />Walton Engineering <br />617238 ciaw A <br />Insurer: State Compensation Ins. Fund <br />Title: Francise Owner <br />P.O Box 1025 <br />916-737-1152 <br />9113339 <br />ICCTech: Tomm Steiger Exp. Date: 2-24-17 <br />ICC Installer: Tomm Steiger Exp. Date: 2-24-17 <br />Manufacturer VMI: Exp. Date: 8-12-16 <br />Trainin : <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Grade: <br />Model: <br />Grade: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />® Leak detector replacement <br />Model: 99LD2000 Serial: 15031415 <br />❑ 87 -octane UST <br />X 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />*This applies only if contractor has all required certifications. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge <br />(ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />r.r,�. e 3 F' p � Accepted By/ "Mn O) <br />