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ENVIRONME0 NTAL HEALTH DE• RTMENT 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* Facinty mtormanon FacilityCostco Wholesale #1031 Fac"'ty 2440 Daniels, Manteca Name: Address: Facirry Dennis Bock Title: Compliance Manager Indicate below type of work to be performed. Check all that apply. 2 Sensor replacement Grade: Model: 323 sin 0331102-002 ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump X91 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: Ll 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. I0 Sensor replacement Model: 304 sin 1010214 ❑ 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 7/8 Mother: Dis enser 9110 annular ❑ 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 c 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#: 0527629 PE: 2361 sc: 098 Assigned To/ ed By.teff Wong } Date: Aug 19, 2014 =HD 23-05 Rev. 07120112 UST RETROFIT VERIFICATION FOF