Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTME <br /> SAN JOAQUIN COUNTY ncCEIVED <br /> 1868 E. Hazelton, Stockton, CA 95205-6232 <br /> Telephone- (209)468-3420 Fax: (209)468-3433 MAR 0 2 2016 <br /> UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE" �TE I nIZ!0..&PTA.Ar=NIT <br /> FacilityInformation <br /> Facility ARCO 6080 <br /> Name: Facility <br /> Address: 85 E. Louise Ave. Lathrop, CA 95330 <br /> Facility Sarah Samuels Title: BP Retail Compiiatim Coordinator <br /> Contact: `- <br /> Contractor Information <br /> Canna <br /> Contractor Gettler Ryan inc, Contractor <br /> Name: Y Address: 6805 Sierra Court, Suite G <br /> CA License n. 93 A. Ha, f925 X51-/5�5 <br /> Number: �20r'J S Class: 7 Contractor r , P <br /> Phone#: <br /> Insurer. Platte River ITIS. C.o. gond#: 41302359 workers, 9051229 <br /> CorW.C <br /> 'cc Tech: Jon Tim Adams Exp.Date: 5/261201 <br /> ICC Installer: Exp.Date: <br /> Manufacturer V@@d8r Root <br /> Trainln Exp.Date: 813/2017 <br /> Indicate below type of work to be performed. Check all that apply. <br /> R Sensor replacement ❑Sensor replacement <br /> Model: 794380-208 Sn:1-15L"A2 <br /> Model: <br /> pz87 piping sump ❑87 fill sump ❑87 piping sump ❑87 fill sump <br /> ❑89 piping sump n 89 fill sump n 89 piping sump ❑89 fill sump <br /> u 91 piping sump n 91 fill sump u 91 piping sump a 91 fill sump <br /> ❑diesel piping sump ❑diesel fill sump ❑diesel piping sump o diesel fill sump <br /> ❑dispenser 112 ❑dispenser 314 ❑dispenser 12 ❑dispenser 3/4 <br /> n dispenser 5/6 o dispenser 7/8 ❑dispenser 5/6 n dispenser 7/8 <br /> ❑other: ❑other: <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> In 87-octane UST n 89-octane UST n 87-octane UST ra-89--octane UST <br /> n 91-octane UST u diesel UST n 91-octane UST n diesel UST <br /> n 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 u 87-octane UST In 89-octane UST <br /> *91-octane UST ri diesel UST ❑91-octane UST a diesel UST <br /> u 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: u 91-octane UST n diesel UST <br /> Disperser: Grade: o other. <br /> 'This applies only if contractor has all required cedifications. <br /> PR#: PRO23-1656 PE: 2351 sc: Q98d To/ kris Veloso Date: Feb 2, 201 <br /> AssigneEHD 2305 Rev 0720/12 UST RETROFIT VERIFICATION FORM <br />