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• 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* �� _:Facil ;Infarinatioa K Facility QuickStop #125 Walto Engineering neer g g Facility 1580 W Main Street, Ripon p Name: 3900 Commerce Dr. W. Sacramento Name: Address: Facility San ram Gill g ❑ other: Title: Owner Contact: Class: A Model: Contractor �� .,� Contractor Walto Engineering neer g g ❑ 91 fill sump contractor 3900 Commerce Dr. W. Sacramento Name: ❑ dispenser 3/4 ❑ dispenser 5/6 Address: ❑ other: CA License 617238 Class: A Model: Contractor 9163721888 Number: ❑ diesel UST ❑ other: ❑ other: Phone #: Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST Workers' ❑ diesel UST Insurer: ❑ other: Comp. #: Model: ICC Tech: Anthony Reyes ❑ 89 -octane UST Exp. Date: Oct 17, 2018 ICC Installer: Exp. Date: Manufacturer Exp. Date: 1/6/2019 Training:SBravo 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: ❑ Leak detector replacement Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Spill container replacement (not direct bury) Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ® Bravo float and chain replacement Dispenser: 3/4 Grade: 91 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#: 0231476 PE: SC: 098 Accepted By/ Zuna Barker Portillo Date: 6/6/2018 Assigned To: EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM