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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 />i • iZ 1 • <br />-•, • V! - . . , 1 • <br />Facility Valero Corner Store #3641 Facility 1210 E Hammer Lane, Stockton <br />Name: Address: <br />Facility <br />Contact: y Penn BroWnwood Title: Manager <br />Contractor <br />Tanknology <br />❑ 89 piping sump <br />Contractor <br />677 E. Lockeford St., Lodi, CA 95240 <br />Name: <br />❑ diesel piping sump <br />❑ diesel fill sump <br />Address: <br />❑ dispenser 3/4 <br />CA License <br />743160 <br />Class: A <br />Contractor <br />209 365-1246 <br />( ) <br />Number: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />x91 -octane UST <br />Phone #: <br />❑ other: <br />Insurer: <br />Brown, Miclette and Britt <br />Model: <br />workers' <br />WCA1520545-10 <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />Com.p. #: <br />❑ other: <br />ICC Tech: <br />Sammy Till <br />Model: <br />Exp. Date: <br />5-29-15 <br />ICC Installer: Exp. Date: <br />Manufacturer Red Jacket Exp. Date: 3-19-15 <br />Traininq: <br />Indicate below type of work to be performed. Check all that apply. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />® Leak detector replacement <br />Model: Red Jacket FX 1V (S/N 116-056) <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />x91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ other: <br />❑ Bravo float and chain replacement <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />Dispenser: <br />Grade: <br />*This applies only if contractor has all required certifications. <br />❑ Sensor replacement <br />Model: <br />❑ 87 piping sump <br />❑ 87 fill sump <br />❑ 89 piping sump <br />❑ 89 fill sump <br />❑ 91 piping sump <br />❑ 91 fill sump <br />❑ diesel piping sump <br />❑ diesel fill sump <br />❑ dispenser 1/2 <br />❑ dispenser 3/4 <br />❑ dispenser 5/6 <br />❑ dispenser 7/8 <br />❑ other: <br />❑ Leak detector replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Spill container replacement (not direct bury) <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />❑ Automatic tank gauge (ATG) replacement <br />Model: <br />❑ 87 -octane UST <br />❑ 89 -octane UST <br />❑ 91 -octane UST <br />❑ diesel UST <br />❑ other: <br />PR#: PR0231125 PE: 2361 I SC: 098 I As gpnted To/ Garrett Backus Date:ceed By,tun 19, 2013 <br />EHD 23-05 Rev. 07/20/12 UST <br />