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• i <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 /> Facilit .Information <br /> Facility USA Gas Station #68154 Facility 2500 W. Lodi Ave. Lodi, CA 95240 <br /> Name: Address: <br /> Facility Title: Environmental Compliance Administrator <br /> Contact.. <br /> hen Coulter <br /> Contractor Information... - <br /> Contractor Service Station Systems Address°f 680 Quinn Ave. San Jose, CA 95112 <br /> Name: <br /> CA license 485184 clas ( )s: 061/D40/HAZ Contractor 408 213-6038 <br /> Number: Phone#: <br /> Insurer: INSURANCE COMPANY OF THE WEST Workers' WPL5021307 <br /> Comp.#: <br /> ICC Tech: Randy Wilkerson Exp.Date: 4/24/2017 <br /> ICC Installer: Exp.Dale: <br /> Tanufaelurer Veeder Root Exp.Date: 5/11/2017 <br /> raInin <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: Model: <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump D 87 fill sump <br /> D 89 piping sump ❑ 89 fill sump D 89 piping sump ❑ 89 fill sump <br /> D 91 piping sump D 91 fill sump D 91 piping sump ❑ 91 fill sump <br /> D diesel piping sump D diesel fill sump ❑ diesel piping sump D diesel fill sump <br /> ❑ dispenser 1/2 ❑ dispenser 3/4 ❑dispenser 1/2 D dispenser 3/4 <br /> ❑dispenser 5/6 D dispenser 7/8 D dispenser 5/6 ❑dispenser 7/8 <br /> D other: D other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑ 87-octane UST ❑ 89-octane UST ❑ 87-octane UST D 89-octane UST <br /> ❑ 91-octane UST ❑diesel UST ❑91-octane UST D diesel UST <br /> ❑other: D other: <br /> El.Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> 87-octane UST D 89-octane UST D 87-octane UST D 89-octane UST <br /> ❑ 91-octane UST D diesel UST ❑ 91-octane UST D 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: D 91-octane UST ❑diesel UST <br /> Dispenser: Grade: xother: Only replaced external light bulb. <br /> *This applies only if contractor has all required certifications. <br /> FIRMPR0231356 PE: 2361 sc: 098 Accepted By/ Aris Veloso Date: Jun 1, 2016 <br /> Assigned To: <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />