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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 Valle Pacific Fresno Ave. Cardlock Name: y Facility 1524 Fresno Ave., Stockton Address: Facility Mike Eliason Contact: Title: Cardlock Manager Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 208 ❑ 87 piping sump Contractor Information ❑ 89 piping sump Contractor Name: Kern County Construction Addressor PO Box 6096, Bakersfield, CA 93386 CA License Number: 481053Class: A Contractor Phone #: 661 634-9950 ( ) Insurer: State Compensation Insurance Fund Workers' 661-0000005 661-0000005 ICC Tech: Josh Simmons Exp. Date: Oct 7, 2015 ICC Installer: ❑ diesel UST Exp. Date: Manufacturer Training: Veeder Root Exp. Date: May 12, 2015 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 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 Xdispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST u other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ 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#: 0506545 PE: 2361I sC: 098 I Accepted By/ StacyRivera I Date: Mar 14, 2014 Assigned To: EHD 23-05 Rev. 07/20/12 UST RETROFIT VERUFICATION FORK