Laserfiche WebLink
• 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 /> Facility intortnatI n <br /> Facility PG&E Facility <br /> Name: Address: 4040 West Lane, Stockton, CA <br /> Facility R. Alex Steele Title: Env. Specialist <br /> Contact: p <br /> Contractor Information <br /> Contractor Gettler Ryan Inc. Contractor 6747 Sierra Court, Suite J, Dublin, CA <br /> Name: Y Address: <br /> CAl.icense 220793 Gass: A Contractor 925-551-7555 <br /> Number: Phone#: <br /> Insurer: Acord Com workers': DTJUB7827P41511 <br /> .# <br /> ICC Tech: Wes Morrison Exp.Date: 9-29-13 <br /> ICC Installer: NSA Exp.Date: <br /> Manufacturer VR level 4 Exp.Date: 6-17-14 <br /> Training, <br /> Inclicate Delow type or worK TO e pe rme . (;heCK sit thatappy. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: %794390-420, S/N 908330 Model: <br /> ❑87 piping sump c 87 fill sump ❑87 piping sump ❑87 fill sump <br /> ❑89 piping sump ❑89 fill sump ❑89 piping sump D 89 fill sump <br /> ❑91 piping sump ❑91 fill sump ❑91 piping sump ❑91 fill sump <br /> ❑diesel piping sump D diesel fill sump ❑diesel piping sump ❑diesel fill sump <br /> ❑dispenser 1/2 ❑dispenser 3/4 o dispenser 1/2 ❑dispenser 3/4 <br /> ❑dispenser 5/6 ❑dispenser 7/8 ❑dispenser 5/6 D dispenser 7/8 <br /> pother: waste oil tank annular sensor D other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> ❑87-octane UST c 89-octane UST ❑87-octane UST ❑89-octane UST <br /> 91 octane UST c diesel UST ❑91octane UST ❑diesel UST <br /> ❑other: ❑other: <br /> ❑Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> D 87-octane UST ❑89-octane UST ❑87-octane UST ❑89-octane UST <br /> D 91-octane UST D diesel UST ❑91-octane UST ❑diesel UST <br /> other. In 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#: 0231963 PE: 2361 sc: 098 Accepted By/ Garrett Backus Date: Se 28, 2012 <br /> Assigned To: p <br /> EH023-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />