COMPLIANCE INFO_2016 - Laserfiche WebLink

Home Browse Search

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* Facdillfty Information Facility Flying J #618 Address: 1501 N Jack Tone Rd., Ripon Contractor Name: Facility Scott Brandu Title: Store Manager Contact: CA License Number: Indicate below type of work to be performed. Check all that apply. N Sensor replacement Contractor information Contractor Name: Jones Covey Grout Contractor Address: 9595 Lucas Ranch Rd., Rancho Cucamong CA License Number: 804431Class: A Haz contractor Phone #: 888-972-7581 Insurer: EVEREST NATIONAL INSURANCE workers' Comp. #: CA10002046161 ICC Tech: ISsac Garcia Exp. Date: 1-24-17 ICC Installer: Issac Garcia Exp. Date: 1-24-17 Manufacturer Training: VR Exp. Date: 2-27-17 Indicate below type of work to be performed. Check all that apply. N Sensor replacement N Sensor replacement Model: VR -208, serial #1060243 Model: VR -303, serial 1506 ❑ 87 piping sump ❑ 87 fill sump ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 xother: UDC 16 (auto side) xother: Diesel 3 annular (1-9) ❑ Leak detector replacement ❑ Leak detector replacement Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Spill container replacement (not direct bury) ❑ Spill container replacement (not direct bury) Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement Dispenser: Grade: Model: Dispenser: Grade: ❑ 87 -octane UST ❑ 89 -octane UST Dispenser: Grade: ❑ 91 -octane UST ❑ diesel UST Dispenser: Grade: ❑ other: *This applies only if contractor has all required certifications. PR#: PR0505264 PE: 2361 SC: 098 1 Accepted By/ Elena Manzo Date: 5-4-16 Assigned To: EHD 23-05 Rev. 07/20/12 UST RETROFIT VERIFICATION FORM