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! ! <br /> 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 /> Facirty 7 Eleven #32.190A Facility 4943 S H 99 Stockton, CA 95215 <br /> Name: Address: <br /> Facility <br /> Contact: .)ivtesh Gill Title: ©caner <br /> Contractor Information <br /> Contractor Tanknology Inc. Contractor 1024 Industrial Wa Suite A-B Lodi„ CA <br /> Name: Address: y= <br /> CA License 743160class: A & Haz Contractor 20_365_1246 <br /> Number: Phone#: <br /> Insurer: Great Divide Insurance Co. workers= <br /> Comp.#: <br /> ICC Tech: Gilbert Garcia Exp.Date: 7-11-15 <br /> ICC Installer. Exp.Date: <br /> Manufacturer Veeder <br /> Traininp' <br /> Root Ex Date: 3-13-15 <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: 794380-208 Model: <br /> ❑87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> x89 piping sump ❑ 89 fill sump ❑ 89 piping sump c 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump <br /> ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑diesel fill sump <br /> ❑dispenser 112 ❑dispenser 314 a dispenser 112 ❑ dispenser 314 <br /> ❑dispenser 516 ❑dispenser 718 c dispenser 516 ❑ dispenser 718 <br /> xother: serial #951710 c other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST ❑ 89-octane UST <br /> c 91-octane UST ❑diesel UST ❑91-octane UST ❑ diesel UST <br /> ❑ other: ❑ other: <br /> Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST © 87-octane UST ❑ 89-octane UST <br /> ❑91-octane UST ❑ diesel UST ❑ 91-octane UST ❑diesel UST <br /> ❑ other: ❑other: <br /> ❑ Bravo float and chain replacement ❑ Automatic tank gauge(ATG)replacement <br /> Dispenser: Grade: Model: <br /> Dispenser: Grade: ❑ 87-octane UST ❑89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST ❑ diesel UST <br /> Dispenser: Grade: ❑ other: <br /> *This applies only if contractor has all required certifications. <br /> PR#: PR0506488 PE: SC: 098 Accepted eAris Veloso Date: Ma 13, 2014 <br /> Assigned To: y <br /> EHD 2305 Rev.07l20N2 UST RETROFIT VERIFICATION FORM <br />