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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 />Fast Lane Central Valley <br />Agnes Malabot <br />Contractor <br />Epic Compliance Systems <br />Name: <br />❑ 87 piping sump <br />CA License <br />Number <br />956593 <br />Class: A <br />Insurer: <br />State Compensation Insurance Fund <br />ICC Tech: <br />Al Milburn <br />ICC Installer: <br />Veeder-Root <br />116 Roth Rd Lathrop CA <br />Title: Store Manager <br />39120 ARGONAUT WAY 643 FREMONT, <br />Contractor 888-700-3742 <br />Phone #: <br />Workers' 1850635 <br />Comp. #: <br />Exp. Date: fT <br />Indicate below type of work to be performed. Check all that apply. <br />® Sensor replacement <br />Grade: <br />Model: Veeder Root 304 Interstitial spacey <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 />Xdispenser W til <br />❑ dispenser 3/4 <br />(�,( X dispenser 5K Ij6 <br />Oi- <br />0❑ ispenser 7/8 <br />" ❑ other: <br />❑ other: <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 />PE:01- D I SC: 098 <br />PR#: I <br />See notes on back of this form <br />❑ Sensor replacement <br />Model: <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 />❑ other: <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 />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST ❑ 89 -octane UST <br />❑ 91 -octane UST ❑ diesel UST <br />❑ other: <br />Accepted By/ <br />Assigned To:�d-- <br />