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W( <br /> �) <br /> (� 0 8 2011 <br /> C i L.-D <br /> ENVIRONMENTAL HEALTH DEPAR-I LINT, <br /> SAN J Ir,j; zo17 <br /> N COUNTY <br /> 1868 E. Hazelton, Stockton, CA 95205-6232 NV I R 0 N NA,E N—i A L H'"ALT <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> PA TMENT <br /> UNDERGROUNDSTORAGETANK <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br /> 'F "I <br /> lnforniation <br /> Facility F <br /> Name: Chevron acility <br /> Address: 1234 E Yosemite Ave., Manteca, CA <br /> Facility Teresa Kennel Title: Manager <br /> Contact: y 9 <br /> Tanknolo Industrial <br /> Contractor Contractor <br /> 9y 1024 Idil W , Suite A S, Lodi <br /> Name: Address: y <br /> CA License 743160 Class: A Haz Contractor 209-365-1246 <br /> Number: Phone#: <br /> Insurer: GREAT DIVIDE INSURANCE COMPANY workers' WCA1920545 <br /> Comp.#: <br /> ICC Tech: Darren Sciume Exp.Date: 6/9/2017 <br /> ICC Installer: Darren Sciume Exp.Date: 6/9/2017 <br /> Manufacturer Veeder Root Exp.Date: 5/4/2017 <br /> TrainIng: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ® Sensor replacement <br /> Model: 409 serial# 1150657/117.75"tank Model: 409 serial#1217407/117.75"tank <br /> ❑87 piping sump ❑87 fill sump o 87 piping sump ❑ 87 fill sump <br /> ❑89 piping sump ❑89 fill sump ❑89 piping sump ❑89 fill sump <br /> 0 91 piping sump ❑91 fill sump ❑91 piping sump ❑91 fill sump <br /> ❑diesel piping sump o diesel fill sump o diesel piping sump o diesel fill sump <br /> o dispenser 1/2 ❑dispenser 3/4 ❑dispenser 1/2 o dispenser 3/4 <br /> ❑dispenser 5/6 ❑dispenser 7/8 o dispenser 5/6 o dispenser 7/8 <br /> cKother: 87 annular, measured at 257.86" xother: 91 annular, measured 259.86" <br /> ❑ Leak detector replacement ❑ Leak detector replacement <br /> Model: Model: <br /> 0 87-octane UST ❑89-octane UST o 87-octane UST o 89-octane UST <br /> 0 91-octane UST o diesel UST ❑91-octane UST ❑diesel UST <br /> ❑other: o other: <br /> ❑ Spill container replacement(not direct bury) ❑ Spill container replacement(not direct bury) <br /> Model: Model: <br /> 0 87-octane UST o 89-octane UST o 87-octane UST o 89-octane UST <br /> 0 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: o 87-octane UST o 89-octane UST <br /> Dispenser: Grade: o 91-octane UST ❑diesel UST <br /> Dispenser. Grade: o other: <br /> `This applies only if contractor has all required certifications. <br /> PR#: 0516248 PE: 2361 sc: Ogg 1 Accepted By! Elena Manzo Date: <br /> Assigned To: <br /> EHD 23-05 Rev.07!20/12 UST RETROFIT VERIFICATION FORM <br />