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11 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 Flying ing J Travel Plaza #618 Facility 1501 N. Jack Tone Road, Ripon, CA. 95366 Name: Address: Facility Scott Brandau Title: General Manager Contact: ..... Sr .. „£ cfa Infarma %ni . Contractor Jones/Cove Group Incorporated Y P p Contractor 9595 LUCAS RANCH ROAD STE 100 Name: ❑ dispenser 1/2 Address: ❑ dispenser 5/6 CA License 804431Class: A/B/HAZ contractor 888 972-7581 ( ) Number: ❑ 87 -octane UST ❑ 89 -octane UST Phone #: ❑ diesel UST Insurer: EVEREST NATIONAL INSURANCE COM Workers' CA10002046 Model: ❑ 87 -octane UST Comp. #: ❑ 91 -octane UST ICC Tech: Rogello Valencia Exp. Date: 4/22/2020 ICC Installer: Model: Exp. Date: ❑ 87 -octane UST Manufacturer Veeder Root Level 4 Exp. Date: 7/25/2018 Training: Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: 0794380-208 ❑ 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 xother: Tank #3 Diesel STP Sump ❑ Leak detector replacement ❑ 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: 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#: 0505264PE: 236 1 SC: 098 1 Accepted By/ Scott Brandau Date: 5/04/2018 Assigned To: EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM