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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 /> fadfitV4n#ormation <br /> Name: Quik Stop Address: 1153 Lincoln Blvd, Tracy CA <br /> Facility g <br /> Contact: Par at Litt Title: Franchisee <br /> Contractor Walton En ineerin contractor PO Box 1025, West Sacramento, 95691 <br /> Name: g g Address: <br /> CA License 617238 Class: A Contractor ( )916 373-1167 <br /> Number: Phone#: <br /> Insurer. QBE Insurance workers'Com .#: QWC4000674 <br /> ICC Tech: Tom Stieger Exp.Date: 3-24-17 <br /> ICC Installer: Exp.Date: <br /> Manufacturer VRlev <br /> Trainin el 4, 12-23-17 Exp. Date: <br /> Indicate below type of work to be performed. Check all that apply. <br /> ® Sensor replacement ❑ Sensor replacement <br /> Model: VR 0794390-409, S/N 1103996 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 ❑ 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 /> xother: 87 tank annular liquid sensor ❑ 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: Grade: Model: <br /> Dispenser: Grade: ❑ 87-octane UST ❑ 89-octane UST <br /> Dispenser: Grade: ❑ 91-octane UST ❑ diesel UST <br /> Dispenser: Grade: ❑ other: <br /> *This applies only if contractor has all required certifications. <br /> PR#: 0231413 PE: 2361 SC: 098 Accepted By/ Garrett Backus Date: Aug6, 2016 <br /> Assigned To: g <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />