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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 /> Faciffty Information <br /> Facility Main Stree Arco Facility <br /> Name: Address: 1100 S Main St <br /> Facility: Jessie Chada Title: 209-825-6784 <br /> Contact <br /> Contractor Information <br /> Contractor Affordatest Contractor 416 2nd St. Galt CA 95632 <br /> Name: Address: <br /> CA License 341375 Class: A Contractor 209-744-0112 <br /> Number: Phone#: <br /> Insurer: Hudson Insurance workers' 30020506 <br /> Comp.#: <br /> ICC Tech: Zane Nimmo Exp.Date: Jun 2, 2019 <br /> ICC Installer: Exp. Date: <br /> Manufacturer Veeder root Exp.Date: JUI 25 2018 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: Veeder root 208 Model: <br /> x87 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 ❑ 91 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: ❑ 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 ❑ 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#: PR0506504 PE: 2300 1 SC: 098 1 Accepted By/ Aaron Han Date: Mar 12 2018 <br /> Assigned To: g <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />