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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* Fa III Information Facility Safe Fuel #2707 y Facility 6425 Pacific Ave., Stockton Name: Address: Facility Singh Title: Safety & Environmental Affairs Manager [(diesel fill sump contractor Address: Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 208 1187 piping sump ❑ 87 fill sump Contractor Information ❑ 91 piping sump Contractor Name: Service Station Stems y [(diesel fill sump contractor Address: 680 Quinn Ave., San Jose, CA 95112 CA License Number 485184 cuss: C-61 D-40 ( ) contractor Phone ft: 408 213-6038 ( ) Insurer. ICW Group ❑ 89 -octane UST workers' #: Com . WPL502130700 ICC Tech: Kris Bell ❑ Spill container replacement (not direct bury) Exp. Date: Oct 2, 2014 ICC Installer: ❑ 89 -octane UST ❑ 91 -octane UST Exp. Date: ❑ other: Manufacturer Veeder Root Training: Exp. Date: Apr 5, 2014 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: Veeder Root 208 1187 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 ❑ other: ❑ 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: ❑ 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 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST 1191 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ 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#: 0231211 PE: 2371 Sc: 098 Accepted By/ Stac Rivera Date: Jan 21, 2014 Assigned To: y