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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 /> Facility Information <br /> Fame:ity Liquor q Address:Lodi Food & Li Facility <br /> Name: 1225 W. Lockeford St. Lodi, CA 95240 <br /> Facility Jaspal Koont Title: owner <br /> Contact: p <br /> Contractor Information <br /> Contractor BZ Maintenance Contractor P.O Box 933 <br /> Name: Address: <br /> CA License 433159class: B, C61, d40 Contractor 209 333-1038 <br /> Number: Phone#: <br /> Insurer: State Compensation Insurance Fund Workers' 9033137 <br /> p Comp.#: <br /> ICC Tech: Kelvin Cruz Exp.Date: 2-11-15 <br /> ICC Installer: Exp.Date: <br /> Manufacturer VMI Exp.Date: 1-8-15 <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ❑ Sensor replacement ❑ Sensor replacement <br /> Model: 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 /> ❑ 91 piping sump ❑ 91 fill sump ❑91 piping sump ❑ 91 fill sump <br /> ❑diesel piping sump ❑diesel fill sump o 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: VMI 99 LD2000 Model: <br /> X 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: o 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: o other: <br /> "This applies only if contractor has all required certifications. <br /> PR#: 0231350 PE: 2361 1 sc: 098 1 Accepted By/ Aris Caca It Date: Nov 20, 2013 <br /> Assigned To: p <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />