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PIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION NOV is 2008 <br /> (One form per project) <br /> I. FACILITY INFORMATION ENVIRONKLNI HENLIH <br /> FACILITY ID#J(Agency Use Only) �. <br /> BUSINESS NAME(Same as FacrlNy.Name or D3BA--Doing Business As) 3. <br /> USA GASOLINE - SRH Food& Gas <br /> BUSINESS SITE ADDRESS 103. 1 CITY 104. <br /> 749 E. Charter Way Stockton Ca <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aaply) 9138. WORK AUTHORIZED UNDER PERMIT 413b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING rNSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SR0055435 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: ��, i 113,. <br /> C,. � �- 4_tYl ' 1?0- 0-CA-EQ;+`c`r{- C} 'rCL . <br /> 'Pic "NJL- <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 412x. <br /> Reliable Petroleum Services Inc. / RobertBarnhart <br /> CONTRACTOR LICENSE# 4121. ICC CERTIFICATION# 482c. <br /> 883706 52522544 UI <br /> IV. 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 Iocal agency, inspected and certified <br /> by a registered professional engineer having education and experience with underground storage tank system installations. <br /> SIGNATURE OF TANK WNER OR OWNER'S AGENT DATE 484 PHONE 487. <br /> CERTIF R' not 4ss. 48&{P ) CERTIFIER'S TITLE: <br /> NAM OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OW NFP ❑ 2.TANK OPERATOR <br /> © 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org <br />