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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 /> UNDERGROUND STORAGE TANK <br /> RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* <br /> Facility Information <br /> Facility adds ss: 2512 E. Waterloo Rd. Stockton, CA 95205 <br /> Name: Waterloo Liquor <br /> Facility g <br /> Contact: Hen Bun Chea Title: owner <br /> Contractor Information <br /> Contractor Elite IV Contractor 2535 Wigwam Dr. Stockton, CA 95205 <br /> Name: Address: g <br /> CA License 660076 Class: A Contractor 209-461-6337 <br /> Number: I Phone#: <br /> Insurer: American Contractors Indemnity Company workers' MWC0070230 <br /> p y <br /> comp.#: <br /> ICC Tech: Michael Kennard Exp.Date: 11-14-16 <br /> ICC Installer: Exp.Date: <br /> Manufacturer <br /> Training: V m 1 Exp.Date: 9-10-16 <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 ❑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: 99LD2000 Model: <br /> ❑87-octane UST ❑89-octane UST ❑87-octane UST ❑ 89-octane UST <br /> ❑91-octane UST xdiesel UST ❑91-octane UST ❑diesel UST <br /> ❑other: serial number 14041344 ❑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#: PR0232418 PE: 2361 1 sC: 098 Accepted Assigned Too:: WIrr, p <br /> s VelosO Date: Apr 20, 2015 <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />