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0 0 ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Arco AM PM #5450 Name: Facility 1617 W. Fremont St., Stockton Address: Facility Contact: Sarah Samuels Title: Environmental Compliance Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: 323 (serial #255563 x87 piping sump ❑ 87 fill sump Contractor Information ❑ 89 fill sump Contractor Name: Gettler-R an Inc y ❑ diesel piping sump Contractor Address: 6747 Sierra Ct., Suite J, Dublin CA 94568 CA License Number: 220793Class: A ❑ other: (87 master) Contractor Phone #: 925 551-7555 ( ) Insurer: Traveler's Property Casualty Co. workers 'mp.. DTJUB78P41510 ICC Tech: Joey Mesa ❑ other: Exp. Date: Apr 30, 2015 ICC Installer: ❑ 87 -octane UST Exp. Date: ❑ 91 -octane UST Manufacturer Training: Level 4 ining:urerVeeder-Root ❑ other: Exp. Date: Oct 29, 2014 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: 323 (serial #255563 x87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: (87 master) ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ *This applies only if contractor has all required certifications. ❑ Sensor replacement Model: ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump 1:191 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: 0231923 1 PE: 2361 sc: 098 1 Accepted To/ Stacy Rivera I Date: Aug 22, 2013