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0 0 <br /> 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 /> ili 01 111 111 <br /> Facility March Lane 76 Facility 2701 March Lane, Stockton <br /> Name: Address: <br /> Facility Darren E ler Title: Manager <br /> Contact: pp er <br /> g <br /> mug� . <br /> contractor SERVICE STATION SYSTEMS INC contractor 680 QUINN AVENUE, SAN JOSE <br /> Name: Address: <br /> CA License 4851184 class: B C-61/D40 contractor 408 971-2445 <br /> Number: Phone#: ( ) <br /> Insurer: INSURANCE COMPANY OF THE WEST Workers' WPL5021307 <br /> Comp.#: <br /> ICC Tech: KRISTOPHER BELL Exp.Date: 08/24/2019 <br /> ICC Installer: Exp.Date: <br /> Manufacturer VEEDER ROOT, BRAVO Exp.Date: 04/12/19, 11/16/2020 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: 208 Model: <br /> ❑ 87 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 /> x91 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: 9/10 Grade: diesel Model: <br /> Dispenser: Grade: ❑ 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 9.1-octane UST ❑ diesel UST <br /> Dispenser: Grade: ❑ other: <br /> *This applies only if contractor has all required certifications. <br /> PR#: PE: SC: 098 Accepted By/ Cesar Ruvalcaba Date: 12/14/2017 <br /> Assigned To: <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />