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UED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION (One form Per Project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ — <br /> 3. <br /> BUSINESS NAME(same.FACMrrx NAS o,DBA-Doing B�si-s:As) <br /> 7-Eleven #32190 <br /> BUSINESS SIE ADDRESS 103 CITY <br /> T <br /> 4943 S. State Hwy 99 Stockton <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aDDly) <br /> ABJe WORK AUTHORIZED UNDER PERMIT 4836. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> x 5.OTHER 483c <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Replaced the Veeder-Root EPCU2 board and cold start and retest. <br /> Replaced the 87 ELLD. <br /> M. CONTRACTOR INFORMATION <br /> 48Ye. <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> Walton Engineering, Inc. aezb482c. <br /> CONTRACTOR LICENSE# . ICC CERTIFICATION# <br /> 617238 5243762-U1 <br /> IV.CERTIFICATION <br /> FTheunderground <br /> the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> ller has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> erground storage tank, any primary piping, and any secondary containment was installed according to applicable consensus standards and any manufacturer's written installation instructions. <br /> listed in the manufacturer's installation checklist has been completed.llation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br /> by a re istered professional engineer having educati7W;7 <br /> h under ound storae a tankosys em installations. 4a <br /> S TUBE OF TANK OWNER OR OWNER'S AGENT <br /> - U •t) (916) 373-1166 <br /> 486. <br /> CERTIFIER'S NAME(print) 'S TITLE:Dulcinea Covan ance Manager 489NAME OF CERTIFIER'S EMPLOYER(DBA) 'S RELATIONSH�TO TANK OWNERWalton Engineering, Inc. . K OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> X 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> Rev.(12/2007) <br /> UPCF UST-C-12 <br />