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INSTALL_2022
Environmental Health - Public
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EHD Program Facility Records by Street Name
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I
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1124
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2300 - Underground Storage Tank Program
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PR0548106
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INSTALL_2022
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Last modified
10/5/2023 4:47:02 PM
Creation date
12/1/2022 9:44:30 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
INSTALL
FileName_PostFix
2022
RECORD_ID
PR0548106
PE
2351
FACILITY_ID
FA0027447
FACILITY_NAME
MOUNTAIN HOUSE CHEVRON
STREET_NUMBER
1124
Direction
N
STREET_NAME
INTERNATIONAL
STREET_TYPE
PKWY
City
TRACY
Zip
95377
CURRENT_STATUS
01
SITE_LOCATION
1124 N INTERNATIONAL PKWY
P_LOCATION
03
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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SITE SKETCH (indicate specifics of tank installation.) <br />. <br />VERIFYING SIGNATURES <br />CONTRACTOR <br />TANK OWNER/REPRESENTATIVE <br />I verify that <br />this information is a true record of the installation <br />of the tanks <br />I verify that this information is a true record of the installation of the tanks <br />listed here. <br />listed here, and that I have received a copy of the Installation Manual <br />and this Tank Installation Checklist. <br />Name: <br />LaiWl I <br />Name: <br />Telephone: <br />((o (4? 3(Q — `-( S -Q v <br />Telephone: <br />Email: <br />ctfINAa,, @ pvc 6 O A+r&C!fZ1IIIII <br />Cvkul <br />Email: <br />Address: <br />32,v(0(A&It-t " ') r <br />Address: <br />/I <br />vt� �Lrr U�j�%Ga r / <br />5 J Z <br />Signature: <br />Signature, <br />Date: <br />J <br />2 <br />Date: <br />J <br />TANK INSTALLATION CHECKLIST <br />Note any variations and/or deviations from <br />instructions (and attach written authorizations): <br />TO INSTALLER: After tank installation, deliverthe Installation Manual with the completed Tank Installation Checklist to the tank owner. Retain a copy of <br />eachforyourrecords. <br />TO OWNER: After installation, retain the limited warranty, the Installation Manual and completed Tank Installation Checklist for future reference and to <br />facilitate any warranty claim. <br />XERXES® 39 <br />BY SHAWCOR <br />. <br />VERIFYING SIGNATURES <br />CONTRACTOR <br />TANK OWNER/REPRESENTATIVE <br />I verify that <br />this information is a true record of the installation <br />of the tanks <br />I verify that this information is a true record of the installation of the tanks <br />listed here. <br />listed here, and that I have received a copy of the Installation Manual <br />and this Tank Installation Checklist. <br />Name: <br />LaiWl I <br />Name: <br />Telephone: <br />((o (4? 3(Q — `-( S -Q v <br />Telephone: <br />Email: <br />ctfINAa,, @ pvc 6 O A+r&C!fZ1IIIII <br />Cvkul <br />Email: <br />Address: <br />32,v(0(A&It-t " ') r <br />Address: <br />/I <br />vt� �Lrr U�j�%Ga r / <br />5 J Z <br />Signature: <br />Signature, <br />Date: <br />J <br />2 <br />Date: <br />TO INSTALLER: After tank installation, deliverthe Installation Manual with the completed Tank Installation Checklist to the tank owner. Retain a copy of <br />eachforyourrecords. <br />TO OWNER: After installation, retain the limited warranty, the Installation Manual and completed Tank Installation Checklist for future reference and to <br />facilitate any warranty claim. <br />XERXES® 39 <br />BY SHAWCOR <br />
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