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0 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* 51- �. y 7 1 '51- ftatlon Facility AT&T California Facility 1812 Cole Avenue, Escalon, CA Y Name: Address: Facility Thu Tran Contact: Y Title: ESM Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: 794380-208 ❑ 87 piping sump ❑ 87 fill sump Contractor Information =,a { -77 Contractor Tait Env. Services Inc. Contractor 701 Parkcenter Drive, Rancho Cordova Name: ❑ dispenser 3/4 Address: ❑ dispenser 7/8 CA License 588098 Class: A I Model: Contractor 714-560-8200 Number: ❑ 91 -octane UST ❑ diesel UST ❑ other: Phone #: ❑ Spill container replacement (not direct bury) Insurer: Travelers Property Casualty Co ❑ 87 -octane UST Workers' U13313182680 ❑ diesel UST ❑ other: ❑ other: Comp. #: ❑ Automatic tank gauge (ATG) replacement ICC Tech: John Cascio ❑ 87 -octane UST Exp. Date: 9-14-17 ICC Installer: John Cascio Exp. Date: 9-14-17 Manufacturer John Cascio Exp. Date: 2-5-17 Training: Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: 794380-208 ❑ 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 [other: transition sump ❑ 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#: PR0231881 PE: 2371 SC: 098 Accepted By/ Elena Manzo Date: Feb 18, 2016 Assigned To: EHD 23-05 Rev. 07/20/12