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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 14971 N HWY 88, Lodi <br /> Facility COUNTRYSIDE LIQUORS & GAS <br /> Name: Address: <br /> Facility gikram Sodhi Title: Manager <br /> Contact: <br /> Contractor Information <br /> ContractorContractor 416 2nd Street, Galt, CA <br /> Name: Afforda -Test Address: <br /> CA License class: A,B,C 10,C20 contractor 209_744-0112 <br /> Number: 341375 Phone#: <br /> Hudson Insurance Company Workers Exempt - No Employees <br /> Insurer: p Y Com .#: p <br /> ICcTech: David Winkler Exp.Date: 1/29/2020 <br /> ICC Installer: Exp.Date: <br /> Manufacturer VMI Exp.Date: 11/09/2019 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: 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 /> ❑other: ❑other: <br /> ❑ Leak detector replacement 10 Leak detector replacement <br /> Model: Model: LD-2000 <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> ❑ 91-octane UST ❑diesel UST x91-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#: PE: SC: 098 Accepted By/ Cesar Ruvalcaba Date: 3/29/2018 <br /> Assigned To: <br /> UST RETROFIT VERIFICATION FORM <br /> EHD 23-05 Rev.07/20/12 <br />