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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Tesoro Shell #68153 Name: Facility 2448 Kettleman Ln Lodi, CA 95240 Address: FacilityGrace Keller Contact: Title: Manager Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 794390-409 ❑ 87 piping sump ❑ 87 fill sump Contractor Information ❑ 89 fill sump Contractor Name: Service Station S stems/Able Maintenance y Contractor Address: 680 Quinn Ave., San Jose, CA 95112 CA License Number: 312844 Class: A ❑ dispenser 7/8 contractor Phone #: 707 545-5522 ( ) Insurer: Insurance Company of the West P Y workers' Comp. #: WPL500060300 ICC Tech: Raamon Frasier Exp. Date: 2-6-15 ICC Installer: Exp. Date: Manufacturer VR Training: Exp. Date: 7-30-13 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 794390-409 ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 xother: existing 87 annular sensor rewired ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Sensor replacement Model: n 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 I other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST u other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST a diesel UST ❑ other: ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement Dispenser: Grade: Model: Dispenser: Grade: ❑ 87 -octane UST ❑ 89 -octane UST Dispenser: Grade: ❑ 91 -octane UST ❑ diesel UST Dispenser: Grade: ❑ other: `This applies only if contractor has all required certifications. PR#: 0231948 PE: 2361 SC: 098 Accepted By/ Aris Cacapit Date: May 29, 2013 Assigned To: EHD 23-05 Rev. 07/20/12 — ^ N n `\ - �'\ UST RETROFIT VERIFICATION