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0 9 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 Information Facility Chevron #208117 Facty 755 S. Trac Blvd., Trac y y Name: Address: Fau'l'ty Andrea Evans Contact: Title: Station Manager Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder-Root 208 (SN 1076367 ❑ 87 piping sump X87 fill sump Contractor Information ❑ 89 fill sump Contractor Name: Tanknolo gy ❑ diesel piping sump Contractor Address: ac Ex p p 11000 N. Mo #500, Austin, TX 7875 CA License Number: 743160 class: A ❑ other: contractor Phone #: 209 365-1246 Insurer: Great Divide Insurance Company ❑ 87 -octane UST comerp.#: WCA1920545 ICC Tech: Jarrod Cooke Exp. Date: Apr 30, 2015 ICC Installer: ❑ 87 -octane UST ❑ 89 -octane UST Exp. Date: ❑ diesel UST Manufa`turerVeeder-Root Training: Level 4 ❑ Automatic tank gauge (ATG) replacement Exp. Date: May 6, 2016 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder-Root 208 (SN 1076367 ❑ 87 piping sump X87 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: ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: Grade: _ ❑ Spill container replacement (not direct bury) Model: ❑ dispenser 1/2 ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Leak detector replacement ❑ 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#: 0508090I PE: 098 I SC: 098 I Accepted By/ StacyRivera I Date: Feb 23, 2015 Assigned To: EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORK