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Amk Alb. <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK. <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project.) <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same.FACndrY NAME?mr DSA—Doing Dus ms As) 3 <br /> US Gasoline <br /> BUSINESS SITE ADDRESS 103 CITY too, <br /> 749 E. Charter Way Stockton,CA 95206 <br /> 11. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) ° WORK AUTHORIZED UNDER PERMIT 431b. <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number or Date). <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SR#0060071 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTdkTED: 4M <br /> 6-9-10 9:00a Tested 89 Annular Space Sensor with EHD Inspector Ray Von Flue and Test Passed. <br /> Sensor SSN:734532 <br /> IIL CONTRACTOR INFORMATION <br /> NAME OF CONT'RACT'OR WIIO PERFORMED INSTALLATION 1 MODIFICATION 4818 <br /> Henderson Maint Co. <br /> CONTRACTOR LICENSE# 4H2b ICC CERT ICATION# hS2c <br /> 856771 6018864-UT <br /> W.CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> voluntary consensus standards and any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> * The installation has been inspected and approved by the local agency,or if required by the local agency,inspected and certified <br /> by a registered professional engineer ha education and ex hence with under ound storage tank s stem installations. <br /> SIGNF 03YNER OR OWNER'S AGENT DATE 484. PHONE 487. <br /> 619110 { } <br /> CERT IER'S NAME(print) 485 CERTIFIER'S TITLE: 486' <br /> Gavin Williams Tech <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> HMC-Henderson Maint Co ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> id 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(1212007) <br />