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• • <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 Quik Stop <br />p <br />Facility 7272 West Lane, Stockton, CA <br />Name: <br />Address: <br />Facility <br />Balwinder <br />Title: Franchisee <br />Contact. <br />Contact: <br />class: <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />Contractor Information <br />❑ 89 piping sump <br />Contractor WaltEngineering <br />Walton neer <br />Name: g g <br />❑ 91 piping sump <br />contractor <br />Address: <br />3900 Commerce Dr., W. Sacramento,cA <br />CA License 617238 <br />Number: <br />class: <br />A B Hazmat <br />contractor <br />Phone #: <br />916-372-1888 <br />Insurer: State Com Ons. Fund <br />Comp <br />Workers' <br />Comp. #: <br />9113339-15 <br />ICC Tech: Jessie Wadkins <br />Exp. Date: <br />4-3-17 <br />ICC Installer: <br />❑ diesel UST <br />Exp. Date: <br />Manufacturer OPW 141220 <br />Training: <br />Model: <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 />❑ 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 ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />® Spill container replacement (not direct bury) <br />Model: OPW P761 C-EVRDV <br />❑ 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 />❑ 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 (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#: PR0231939 I PE: 2361 I SC: 098 I Assigned To, I Date: 7-27-2016 <br />9171 9690 0935 0118 0894 06 <br />