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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 /> Facility Information <br /> Fa°'rry 7-Eleven Faclnty 4501 N PershingAve, Stockton, CA <br /> Name: Address: <br /> Facility Hanesh Chauhan Title: Franchisee <br /> Contact: <br /> Contractor Information <br /> Contractor Tanknolo Contractor <br /> Name: 9y Address: 1024 Industrial WayA-B, Lodi, CA 95240 <br /> CA License 743160 class: A contractor 209 365-1246 <br /> Number: Phone#: ( ) <br /> Insurer: Grt-mow{— ''�rVlc�n—`l.e-+�ynP4+�e�� Comp Worke#: ?JcA 1 9'ZOS5Lf5 <br /> ICC Tech: Jarrod Cooke exp.Date: 1-10-14 <br /> ICC Installer: Exp.Dale: <br /> Manufacturer Veeder Root TLS-3XX Exp.Date: 5-7-14 <br /> Training: <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 D 87 fill sump D 87 piping sump D 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump D 89 piping sump D 89 fill sump <br /> ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump D 91 fill sump <br /> ❑diesel piping sump ❑diesel fill sump ❑ diesel piping sump D diesel fill sump <br /> ❑ dispenser 1/2 ❑dispenser 3/4 D dispenser 1/2 D dispenser 3/4 <br /> ❑dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> ❑other: D other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> D 87-octane UST ❑ 89-octane UST ❑ 87-octane UST D 89-octane UST <br /> D 91-octane UST ❑ diesel UST ❑ 91-octane UST D 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 n 89-octane UST ❑ 87-octane UST D 89-octane UST <br /> ❑ 91-octane UST D diesel UST D 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: ❑ 91-octane UST D diesel UST <br /> Dispenser: Grade: ❑other: <br /> Co�� <br /> *This applies only if contractor has all required certifications. <br /> PR#: 231233 PE: 2361 SC 098 Accepted By/ Garrett Backus Date: Oct 11, 2013 <br /> Assigned To: <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />