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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 /> IFacility <br /> � ,..1actttt`at'rsrtlon.,. <br /> Name: Valley Pacific Fresno Ave Cardlock aaa�ss: 1501 W. Charter Way, Stockton <br /> Facility <br /> Mike Eliason Title: Cardlock Manager <br /> Y�r {]y �E�f yyjy4Grr_... .n°4 Ate .. <br /> Contractor Tank-Tek Contractor PO Box 5850 Riverside CA 95217 <br /> Name: Address: + <br /> CA License 803705 Class: contractor <br /> Number: Phone#: (707) 779-4999 <br /> Insurer: workers'Com .#: <br /> ICC Tech: Richard Thomas Exp.Date: Dec 5, 2016 <br /> ICC Installer: Exp.Date: <br /> Manufacturer Veede <br /> Training: + <br /> r Root Exp.Date: Dec 10 2016 <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: Veeder-Root 420 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 1:191 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 /> xother: south diesel piping ❑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#: 0231989 PE: 2361 SC: 098 1 Accepted By/ StacyRivera Date: Mar 11, 2016 <br /> Assigned To: <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />