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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 Food For Less Fuel Center Facility <br /> Name: Address: y 3408 Manthe Rd., Stockton <br /> Facility er Jesus Jurado Title: Compliance Manager <br /> Contact: p g <br /> Contractor Information <br /> Contractor SERVICE STATION SYSTEMS INC Contractor <br /> Name: Address: 680 QUINN AVENUE, SAN JOSE <br /> CA License 485184 Class: B C-61/13140 contractor 408 971-2445 <br /> Number: Phone#: ( ) <br /> Insurer: INSURANCE COMPANY OF THE WEST Workers' WPL5021307 <br /> Comp.#: <br /> ICC Tech: Kristopher Bell Exp.Date: 08/24/2018 <br /> ICC Installer: Exp.Date: <br /> Manufacturer Veeder Root Exp.Date: 4/12/2019 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ® Sensor replacement <br /> Model: 208 Model: 460 <br /> ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump <br /> ❑ 91 piping sump X91 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 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> ❑ other: xother: 87/91 Annular <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: ❑ 91-octane UST ❑ diesel UST <br /> Dispenser: Grade: ❑ other: <br /> "This applies only if contractor has all required certifications. <br /> PR#: PE: SC: 098 Accepted By/ Cesar Ruvalcaba Date: Dec 13, 2017 <br /> Assigned To: <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />