COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

ENVIRON •NTAL HEALTH DE •RTMENT 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* Facility Information Facility March Lane 76 Fac ty 2701 W. March Lane Name: Address: Facility Darren Eppler Title: Manager Contact: 485184 Indicate below type of work to be performed. Check all that apply. ❑ Sensor replacement Model: ❑ 87 piping sump contractor Inforrnation ❑ 89 piping sump Contractor Name: Service Station Systems, Inc %/ Contractor Address: 680 Quinn Avenue Nu License Number: 485184 class: C-61 (D-40) Phone #or 408-213-6038 Insurer: Insurance Company of the West p Y Workers Comp. #: WPL 502190702 ICC Tech: Service Technician/ Kris Bell Exp. Date: Sep 11, 2016 ICC Installer: ❑ other: Exp. Date: ❑ Spill container replacement (not direct bury) Manufacturer Train ing: Bravo Exp. Date: Dec 5, 2017 Indicate below type of work to be performed. Check all that apply. ❑ 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: ❑ dispenser 3/4 ❑ Leak detector replacement Model: ❑ other: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ 89 -octane UST ❑ Spill container replacement (not direct bury) Model: ❑ other: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ 89 -octane UST ® Bravo float and chain replacement Dispenser: 112 Grade: 91 -octane Dispenser: Grade: Dispenser: Grade: Dispenser: Grade: *This applies only if contractor has all required certifications. ❑ 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 ❑ 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: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: PR0231176 I PE: 2300( sc: 098 I Accepted By/ Fatinah Zareef I Date: Dec 17, 2014 Assigned To: EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORN