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• <br />0 <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 CRLLC/ United # 5446 <br />Facility 1403 W. Count Club Blvd, Stockton, CA <br />Country <br />Name: <br />Address: <br />Facility <br />Panhia Vue <br />Title: Manager <br />g er <br />Contractor <br />Phone #: <br />951 779-4999 <br />( ) <br />Contractor Information <br />❑ 87 fill sump <br />Contractor Tank Tek- Environmental Corporation <br />Name: p <br />Contractor <br />Address: <br />3672 Chicago Ave, Riverside, CA 92507 <br />g <br />CA License 803705 <br />Number: <br />Class: A <br />Contractor <br />Phone #: <br />951 779-4999 <br />( ) <br />Insurer: p <br />State Compensation Insurance Fund <br />Workers' <br />Comp. #: <br />9002467 <br />ICC Tech: Richard Thomas <br />Exp. Date: <br />12-5-16 <br />ICC Installer: Richard Thomas <br />Exp. Date: <br />11-10-16 <br />Manufacturer VMI Installer <br />Training: <br />Exp. Date: <br />12-29-16 <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: 99 LD 2000 (16021590 <br />x 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <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 (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#: PR0231995 I PE: 2361I SC: 098 I Accepted By/ Fatinah Zareef Date: May 11, 2016 <br />Assigned To: y <br />EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORK <br />