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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 />Facility Fast Lane Central Valle LLC <br />Name: y <br />Facility <br />Roth Road, Lathrop, CA <br />Address: 116 p' <br />Facility Agnes Mabalot <br />act: g <br />Title: Manager <br />9 er <br />Indicate below type of work to be performed. Check all that apply. <br />R Sensor replacement <br />Model: 0794380-208 <br />❑ 87 piping sump <br />contractor Information <br />❑ 89 piping sump <br />Contractor <br />Name: <br />EPIC Environmental Comp liance Sy stem <br />Contractor <br />Address: <br />39120 Argonaut Way #643, Fremont, CA <br />9 y <br />CA License <br />Number: <br />956593Class: <br />A <br />Contractor <br />Phone #: <br />888 -700 -EPIC <br />Insurer: <br />American Contractors Indemnity Co. <br />`� <br />Workers' <br />Comp. #: <br />1850635 <br />ICC Tech: <br />Alvin Milburn <br />Exp. Date: <br />February 14, 2017 <br />ICC Installer: <br />Exp. Date: <br />Manufacturer <br />Training: <br />Veeder Root <br />Exp. Date: <br />July 12, 2017 <br />Indicate below type of work to be performed. Check all that apply. <br />R Sensor replacement <br />Model: 0794380-208 <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 />xdiesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: Diesel North STP Sump <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <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: 0794380-208 <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 />xdiesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: Diesel South STP Sump <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 />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 91 -octane UST <br />❑ other: <br />❑ 89 -octane UST <br />❑ diesel UST <br />PR#: 0523684 PE: 2351I SC: 098 Accepted ByN" Date: 06/17/2016 <br />Assigned To' <br />EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM <br />