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9 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 /> Facilli4ty Information <br /> FacilityUnited #5447 Facility 1469 E Hammer Lane <br /> Name: Address: <br /> Facility Tom Robins Title: Environmental Contact <br /> Contact: <br /> . Contractor lnforriiation <br /> Contractor CGRS Contractor 5444 Dry Creek Rd. <br /> Name: Address: <br /> CA License class: A 9103616 Contractor 916-303-0408 <br /> Number: Phone#: <br /> Insurer: American Contractor's Indemnity Co. Comer p.#: WC4632690 <br /> ICC Tech: Richard Thomas Exp.Date: Nov 17, 2018 <br /> ICC Installer: Exp.Date: <br /> Manufacturer VR Exp.Date: Nov 13, 2018 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: 0794380-409 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 /> Mother: 89 annular ❑ 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 /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <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 /> ❑ 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#: 0231126 PE: 2300 SC: 098 Accepted By/ Aaron Han Date: Au 2, 2018 <br /> Assigned To: g g <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />