COMPLIANCE INFO_2012-2016 - Laserfiche WebLink

Home Browse Search

ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Quik StopMarket #3138 Facility 1153 Lincoln Blvd., Trac y Name: Address: Facility Par at Litt g Title: Franchisee Contact: P.O. Box 1025, West Sacto, CA 95691 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model. 208 x87 piping sump ❑ 87 fill sump Contractor Information ❑ 89 fill sump Contractor Name: Walton Eng ineering ❑ diesel piping sump contractor Address: P.O. Box 1025, West Sacto, CA 95691 CA License Number: 617238 Class: A ❑ other: Contractor Phone #: 916 373-1167 Insurer: QBE Insurance Corp.orkers' p ❑ 87 -octane UST Comp. #: QWC4000647 ICC Tech: Jessie Wadkins Exp. Date: Apr 29, 2015 ICC Installer: ❑ 87 -octane UST ❑ 89 -octane UST Exp. Date: ❑ diesel UST Manufacturer Veede Training:r-Root Level 4 Exp. Date: May 4, 2015 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model. 208 x87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST 0 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: Dispenser: Grade: Dispenser: Grade: Dispenser: Grade: *This applies only if contractor has all required certifications. ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump o 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump o diesel fill sump ❑ dispenser 1/2 o dispenser 3/4 ❑ dispenser 5/6 o dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: 0231413 I PE: 2361 I sc: 098 I Assigned By/ Stacy Rivera I Date: Aug 20, 2014 Rev. 07/20/12 UST