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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY U 4L., %# L_ <br />1868 E. Hazelton, Stockton, CA 95205-6232 SEP 0 I <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANKf <br />RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE*' _ <br />Facility Information <br />Facility Quik Stop <br />p <br />Fac�ldy 7272 West Lane, Stockton, CA <br />Name: <br />Address: <br />Facility <br />Contact: Somal Balwinder <br />Title: Franchisee <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />Contractor: <br />Information <br />0 91 piping sump <br />Contractor <br />Name: <br />neer <br />Walton Engineering <br />9 g <br />❑ diesel fill sump <br />Address: Contractor <br />Addre <br />3900 Commerce Dr., W. Sacramento,cA <br />CA ucense <br />Number: <br />617238 <br />class: A B Hazmat <br />contractor <br />Phone #: <br />916-372-1888 <br />Insurer: <br />State Comp Ons. Fund <br />Wor ers' <br />9113339-15 <br />ICC Tech: <br />Jessie Wadkins <br />0 other: <br />Exp. Date: <br />4-3-17 <br />ICC Installer: <br />❑ 87 -octane UST <br />Exp. Date: <br />❑ 91 -octane UST <br />Manufacturer <br />Training:141220 <br />OPW <br />Exp. Date: <br />12-18-16 <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />1189 fill sump <br />0 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 />o other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST o 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />® Spill container replacement (not direct bury) <br />Model: (DPW P761C-EVRDV <br />o 87 -octane UST ❑ 89 -octane UST <br />X91 -octane UST ❑ diesel UST <br />X 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 />o 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />o diesel fill sump <br />o dispenser 1/2 <br />o 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 />o diesel UST <br />0 other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />o 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />0 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#: PR0231939 I PE: 2361 1 sc 098 1 A ce ed Ta' I Date: 7-27-2016 <br />