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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 Arco Station #6080 Facility 85 East Louise Ave. <br /> Name: Address: <br /> Facility <br /> Terri Malay Title: Store Manager <br /> Contractor Information <br /> Contractor Getter-R Inc Contractor <br /> an <br /> Name: y Address: 6805 Sierra Court, Suite G <br /> CA License 220793 class: A/B/C-61/D40, contractor <br /> —Number. Phone#: 925-551-7555 <br /> Insurer: North American Specialty Insurance Comp Workers 9051229 <br /> Comp.#: <br /> ICC Tech: David Rouse Exp.Date: 7/23/2018 <br /> ICC Installer David Rouse Exp.Date: 6/12/2019 <br /> Manufacturer <br /> Training: Veeder-Root Exp.Date: 7/28/2020 <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: Veeder Root 208 Sensor(794308-:d Model: <br /> n 87 piping sump n 87 fill sump n 87 piping sump x 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 xdispenser 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 n 91-octane UST ❑ diesel UST <br /> ❑ other: u 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 /> n 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#: PR0231656 PE_ 2351 sc 098 AccepteaBy/ David Rouse Date: 1-29-2018 <br /> Assigned To: <br /> EHD 23-05 Rev_07/20/12 UST RETROFIT VERIFICATION FORM <br />