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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 /> Facillitv Information <br /> Facility ARCO Facility 2908 Ben Holt Drive, Stockton <br /> Name: Address: <br /> Facility Wight Title: Owner <br /> Contact: Kathyy g <br /> Contractor Information <br /> ContractorB Z Service Station Maintenance Contractor <br /> Name: Address: P.O. Box 933, West Sacramento 95691 <br /> CA License 433159 Class: B D-40 Contractor 916-371-2380 <br /> Number: Phone#: <br /> Insurer: Financial Pacific 91015254 Workers' 9033137 <br /> Comp.#: <br /> ICC Tech: Rhome Desbiens Exp.Date: 1-24-15 <br /> ICC Installer: Exp.Date.. <br /> Manufacturer Veeder Root level 4 Exp.Date: 3-6-15 <br /> Training: <br /> Indicate below pe o wo o be peffo-r-m-607-CheCK all thatappy. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: Veeder Root 208 Model: <br /> ❑87 piping sump OK87 fill sump ❑ 87 piping sump ❑ 87 fill sump <br /> ❑89 piping sump ❑89 fill sump 1189 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#: 0231021 PE: 2361 sc: 098 Accepted By/ Garrett Backus Date: Jan 15, 2014 <br /> Assigned To: <br /> EHD 2305 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />