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ENVIRON •NTAL 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 QuickSto #2121 Name: p Facy 1196 W Louise Ave Address: Facility Sue Kaur Contact: Title: Franchise's wife Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump Contractor Information ❑ 89 fill sump Contractor Walto Eng ineering ❑ diesel piping sump Contractor 3900 Commerce Dr. W. Sacramento Name: ❑ dispenser 5/6 ❑ dispenser 7/8 Address: ❑ dispenser 3/4 CA License 617238 Class: A contractor 9163721888 Number: Model: Phone #: ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: Workers' ❑ Spill container replacement (not direct bury) Insurer: ❑ 87 -octane UST Comp. #: ❑ 91 -octane UST ICC Tech: Anthony Reyes Exp. Date: Oct 17, 2018 ICC Installer: ❑ 87 -octane UST ❑ 89 -octane UST Exp. Date: ❑ diesel UST Manufacturer OPW Exp. Date: 1/1/2019 Training: Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement Model: ❑ 87 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: ❑ dispenser 3/4 ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ® Spill container replacement (not direct bury) Model: P51 1 C-DEVRBUCKET ❑ 87 -octane UST ❑ 89 -octane UST X91 -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 ❑ 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 ❑ 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#: P R0231430 PE: SC: 098 1 Accepted By Assigned To/ Date: 9- 2Z . EHD 23-05 Rev. 07/20/12 -��` ' UST RETROFIT VERIFICATION FORW