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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 /> Facility Information <br /> Facility Pilot Travel Centers LLC Facility 1501 N Jack Tone Rd, Ripon, CA <br /> Name: Address: p <br /> Facility an Cairns <br /> Contact: Bryan Title: Manager <br /> Contractor Information <br /> Contractor Contractor (^ <br /> Name: U Address: ,� <br /> CA License Class: Contractor <br /> Number: Phone#: <br /> Insurer: ' Workers' /n1A <br /> S'tdN �N Comn.#:C Q <br /> ICC Tech: Raul Garcia Exp.Date: I a <br /> ICC Installer: Raul Garcia Exp.Date: I <br /> Manufacturer Raul Garcia Exp.Date: _ <br /> Training: <br /> Indicate below type of work to be performed. Check all that apply. <br /> Sensor replacement ❑ Sensor replacement <br /> 1 Model: Model: <br /> ❑ 87 piping sunip ❑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 /> ❑dispens r 5/6 ❑d' pe ser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 <br /> other: LP,%O s ❑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#: <br /> OL?V D V PE:� 6 SC: 098 As gnted ed By/ in Date: <br /> To: �—15-I <br /> EHD 23-05 Rev.07/20/12 UST RETROFIT VERIFICATION FORM <br />