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9 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 /> Facilky Information <br /> Facility Pilot Travel Centers LLC Facility 1501 N Jack Tone Rd, Ripon, CA <br /> Name: Address: p <br /> Facility Bryan Cairns Tine: Manager <br /> tact: <br /> Conry 9 <br /> contractor Information <br /> Contractor (? Contractor (]t q <br /> Name: b Vt;N Qti(, Address: <br /> CA License QQ 2U Class: Contractor C� �1 eQ Kq p <br /> Number. OU/ J Q,�. Phone#: /� ` <br /> Insurer. 'Qv 0 h0- T y1 ComWorkes' C V ' I <br /> ICCTech: Raul Garcia c C Exp.Date: <br /> ICC installer Raul Garcia I Cly Exp.Date: —( �H <br /> Manufacturer Raul Garciat</� Exp.Date: —a� — QTraini <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> Model: 0:104 M4D-U'� Model: <br /> ❑ 87 piping sump 1187 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: ��l� Mpg 5�p ❑ other: <br /> Leak detector re laceme it ❑ Leak detector replacement <br /> Model: �,N o STP ML <br /> / 'D ,U�-�(�W) Model: <br /> Y87-octane UST ❑89-octane UST ❑87-octane UST ❑ 89-octane UST <br /> ❑91-octa�le UST ❑dies UST ❑ 91-octane UST ❑diesel UST <br /> ❑other: MCI � q` '�1(� ❑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#:1) PE:a3b2 SC: U9$ AssignedTBo Date: —I�— <br /> EHO 23-05✓✓R``e'v✓✓0 20/12 UST RETROFIT VERIFICATION FORM <br />