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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 />Fa Name: ty Arco AM Pm #82602 <br />aad� ss: 2430 Joe Pombo Way PKWY <br />Facility <br />Contact: Vikram Singh h <br />Title: Owner <br />Indicate below type of work to be performed. Check all that apply. <br />R Sensor replacement <br />Model: (serial 11504999) -- 409 <br />❑ 87 piping sump <br />Contractor Information <br />❑ 89 piping sump <br />Contractor Guadalupe Sanchez <br />Name: <br />❑ 91 piping sump <br />Amesor <br />3619 King Court <br />CA License C61 /D40A <br />Number: <br />class: A <br />❑ dispenser 3/4 <br />Contractor <br />Phone #: <br />925-470-0803 <br />Insurer: Acord 35076 <br />workers' <br />Comp. #: <br />9214798-17 <br />ICC Tech: #5250451 <br />Exp. Date: <br />4-8-2019 <br />icc installer: #5250451 <br />❑ diesel UST <br />Exp. Date: <br />12-29-2018 <br />Manufacturer Veeder-Root <br />Training: <br />Model: <br />Exp. Date: <br />11-2-2017 <br />Indicate below type of work to be performed. Check all that apply. <br />R Sensor replacement <br />Model: (serial 11504999) -- 409 <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />pother: 91 Annular <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 91 -octane UST <br />❑ other: <br />❑ 89 -octane UST <br />❑ diesel UST <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />Dispenser: <br />Grade: _ <br />*This applies only if contractor has all required certifications. <br />® Sensor replacement <br />Model: (serial 1030382) 79438-208 <br />❑ 87 piping sump <br />X87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#: PRO506796 i PE:2,31LnI, I sc: 098 I Ascnpned <br />i -d Bye __/// I Date: 10-19-2017 <br />EHD 23-05 <br />