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' 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 Quik Stop #3114 Facility 7272 West Lane, Stockton, CA <br /> Name: Address: <br /> Facility Paul Somal Title: Manager <br /> Contact: g <br /> Contractor Walton Eng ineering contractor P.O. Box 1025 West Sacto CA 95691 <br /> Name: Address: <br /> CA License 617238 Class: A Contractor ( )916 373-1172 <br /> Number: Phone#: <br /> Insurer: Sea Bri ht Workers' BB1093003 <br /> g Comp.#: <br /> ICC Tech: Jessie Wadkins Exp.Date: 4-29-15 <br /> ICC Installer: Exp.Date: <br /> Manufacturer OPWEVR phase 1 Exp.Date: 12-14-14 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump <br /> ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump <br /> ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 1/2 ❑ dispenser 3/4 <br /> ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> ❑ other: ❑ other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑ other: ❑ other: <br /> M Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: OPW 1-2100 Model: <br /> ❑ 87-octane UST x89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑ diesel UST ❑ 91-octane UST ❑ diesel UST <br /> ❑ other: ❑ other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: ❑ 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST ❑ diesel UST <br /> Dispenser: Grade: ❑ other: <br /> 'This applies only if contractor has all required certifications. <br /> PR#: 231939 PE: 2361 SC: 098 Accepted By/ Garrett Backus Date: Au 2 2013 <br /> Assigned To: g <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />