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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 /> Facli Information <br /> FadlitNameY Valley Pacific Petro. - Hwy 99 Facility Address: 3550 S. Hwy 99, Stockton <br /> Contact. Mike Eliason True: Cardlock Manager <br /> contractor Information <br /> Contractor Tank-Tek Environmental Contractor 607 Elmira Rd., Vacaville, CA 95687 <br /> Name: Address: <br /> CA License 803705 class: A PCon <br /> hone ctor <br /> # (707) 446-6151 <br /> Number: <br /> Insurer. State Compensation Insurance Fund workers' 90024672013 <br /> Com .#: <br /> ,cc Tech: Richard Thomas Exp.Date: Dec 27, 2014 <br /> ICC Installer: Exp.Date: <br /> Manufacturer VR Level 4 Date: Dec 9, 2014 <br /> Trainin : Exp. <br /> Indicate below type of work to be performed. Check all that apply. <br /> a CMA start of 7LS -3&0 <br /> ® Sensor replacement [9 Sensor replacement <br /> Model: VR 420 Model: VR 208 <br /> ❑87 piping sump 1187 fill sump x87 piping sump ❑ 87 fill sump <br /> ❑89 piping sump ❑89 fill sump ❑89 piping sump ❑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 1/2 ❑dispenser 3/4 ❑dispenser 1/2 ❑dispenser 3/4 <br /> ❑dispenser 5/6 ❑dispenser 7/8 In dispenser 5/6 ❑ dispenser 7/8 <br /> [$other: annular ❑ 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 /> ❑ 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: u 91-octane UST ❑diesel UST <br /> Dispenser: Grade: ❑other: <br /> `This applies only if contractor has all required certifications. <br /> PR#: 0505827 PE: 2361 1 se: 098 1 Accepted Byi St ac Rivera Date: Apr 2, 2013 <br /> Assigned To: y p <br /> EHD 23-05 Rev.07/20112 UST RETROFIT VERIFICATION FORM <br />