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2018 FEB 5 - ENVIRONMENTAL HEALTH DEPARTMENT Chevron #208117 UMA MT. 9011171111111 SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: is 468-3433 MENEM= Indicate below type of work to be performed. Check all that apply. moot "I U*4134 * 87 piping sump o 87 fill sump * 89 piping sump 1189 fill sump * 91 piping sump 0 91 fill sump * dlesel piping sump o diesel fill sump * dispenser 1/2 a dispenser 3/4 * dispenser 516 o dispenser 7/8 * other: o dispenser 3/4 * dispenser 5/6 n dispenser 7/8 * other: 'cc Tech-, Timothy Elebeck A Exp-Date 6/16/2019 Manufacturer —Training: Phil-Tite EVR Phase 1 m�� Exp. Date: March 6, 2017 Indicate below type of work to be performed. Check all that apply. moot "I U*4134 * 87 piping sump o 87 fill sump * 89 piping sump 1189 fill sump * 91 piping sump 0 91 fill sump * dlesel piping sump o diesel fill sump * dispenser 1/2 a dispenser 3/4 * dispenser 516 o dispenser 7/8 * other: o dispenser 3/4 IF Leak detector replacemenA, Model: c3 87 -octane LIST a 89 -octane List— * 91 -octane UST 13 diesel LIST * other o 87 -octane UST o gin_ LIST cK 91 -octane UST o diesel LIST o other W, Bravo float and chain replacement Dispenser: Grade: Dispenser. Grade: Dispenser Grad - i •^ DispeGrade: W Sensor replacement Model: * 87 piping sump o 87 fill sump * 89 piping sump o 89 fill sump * 91 piping sump 0 91 fill sump * diesel priping sump u diesel fill sump * dispenser 1/2 o dispenser 3/4 * dispenser 5/6 n dispenser 7/8 * other: X • = =W, I • 87 -octane LIST o 86 ---octane UST___ • 91-octan'e LIST o diesel UST • other: Model: • 87 -octane UST o 89 -octane LIST c' A • 91'o t 'e LIST o diesel LIST • other, • 87 -octane LIST o 89 -octane LIST_ • 91 -octane UST a diesel UST • other: PR#: PRO508090 1 'c-Pted 'Y' Timthy Elebeck Assigned To: o�