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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 6080 Facty 85 E. Louise Ave. Lathrop, CA 95330 <br /> Name: Address: <br /> Facility Sarah Samuels TitCompliance BP Retail Cllance Coordinato <br /> Contact: araamuep <br /> Contractor Information <br /> Contractor Getfifer R an Inc. contractor 6805 Sierra Court, Suite G <br /> Name: y Address: <br /> CA License 220793class: A Haz Contractor (925) 551-7555 <br /> Number: Phone#: <br /> Insurer: Platte River Ins. Co. Bond #: 41302359 Workers' 9051229 <br /> Comp.#: <br /> ICC Tech: Jon Tim Adams Exp.Date: 5/26/2017 <br /> ICC Installer: Exp.Date: <br /> Manufacturer Veeder Root Exp.Date: 8/3/2017 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> IR Sensor replacement ❑ Sensor replacement <br /> Model: 794380-208 sn:1158827 Model.- <br /> x87 <br /> odel: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 /> Fi 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 i 91-octane UST ❑ diesel UST <br /> ❑ other: r I 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: r_I other: <br /> `This applies only if contractor has all required certifications. <br /> PR#: PR0231656 PE: 2351 SC: 098 IBy/Accepted Assigned To:To: Aris Veloso Date: Feb 2. 2016 <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />