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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 Informatlon Facility Costco Wholesale # 1031 Facility 2440 Daniels St, Manteca, CA 95337 Name: Address: Facility Dave Zizzo Contact: Title: Supervisor Indicate below type of work to be performed. Check all that apply. R Sensor replacement Model: 0332117-001 Serial # 1053060 ❑ 87 piping sump Contractor Information ❑ 89 piping sump Contractor AIITech Petro Inc _ Contactor PO Box 4208 Sonora, CA 95370 Name: ❑ dispenser 112 Address: ❑ dispenser 5f6 CA License 623541 class: A-HAZ contractor 209-532-7320 Number: ❑ 87 -octane UST Phone #: ❑ 91 -octane UST Insurer: State Fund ❑ other: workers comp, #: 1940433 ICC Tech: Isaac Anderson ❑ Spill container replacement (not direct bury) Exp. Cate: Jun 22, 2016 ICC Installer. ❑ diesel UST Exp. Date: ❑ diesel UST Manufacturer VR Exp. Date: Sep 26, 2016 Trainin : ❑ 87 -octane UST ❑ 89 -octane UST Indicate below type of work to be performed. Check all that apply. R Sensor replacement Model: 0332117-001 Serial # 1053060 ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump d 89 fill sump ❑ 91 piping sump ❑ 91 fill sump diesel piping sump ❑ diesel fill sump ❑ dispenser 112 ❑ dispenser 314 ❑ dispenser 5f6 ❑ dispenser 718 D(other: 87A Product S9 Vac Sensor ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ diesel UST ❑ Spill container replacement (not direct bury) Model: ❑ Spill container replacement (not direct bury) ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ diesel UST ❑ 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 112 ❑ dispenser 314 ❑ dispenser 516 ❑ dispenser 718 ❑ 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 LIST ❑ diesel UST ❑ other: PR#: 0527629 PE: 2300 sc: 098I Accepted By/ Fatinah Zareef Date: Aug 19, 2015 Assigned To: EHO 23-05 Rea. 07120/12 UST RETROFIT VERIFICATION FORE