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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 /> Facility Lodi Muni Service Center Facility 1331 S. Ham Ln. Lodi, CA 95240 <br /> Name: Address: <br /> Facility Rand LTitle: Fleet Services Supervisor <br /> Contact: Randy y p <br /> Contractor Information <br /> Contractor y g Ba le Enterprises INC Contractor 2370 Maggio Circle #4 Stockton, CA <br /> Name: Address: <br /> CA License 774802 Class: C-61 (D-40) ContractPhone#or 209 333-6800 <br /> Number: <br /> Western Surety Company Com an <br /> Workers' State Compensation <br /> Insurer: Comp.#: <br /> ICC Tech: Eric Mulgard Exp.Date: 2-12-15 <br /> ICC Installer: n/a Exp.Date: n/a <br /> Manufacturer yr Exp.Date: 10-27-14 <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 ❑ 87 fill sump n 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump 191 fill sump ❑ 91 piping sump �-j 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 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> ❑ other: L 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 n_ 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 I1 diesel UST <br /> ❑ other: ❑ other: <br /> ❑ Bravo float and chain replacement ® Automatic tank gauge (ATG) replacement <br /> Dispenser: Grade: Model: 790091-001 SN#098217 <br /> Dispenser: Grade: X 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST ❑ diesel UST <br /> Dispenser: Grade: xother: replaced external audible/visual <br /> 'This applies only if contractor has all required certifications. <br /> PR#: PR0231332 PE: 2361 SC: 098 Accepted Assigned To/ByAris Cacapit Date: Sep 27, 2013 <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />