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!01/11/ 4:06 2094654988 HMC PAGE 01/01 <br /> 'V': UD <br /> RDECEI <br /> JAN UNIFIED PROGRAM C;ONSOLIi)ATE'D FORM <br /> IEN IRO) WW HEPJR UNDERGROUND STORAGE TANK <br /> EERP T,°SERVI!CE.S CLR."TTFiCA,TTON OF iNSTALLATiON / MODIFiCATION(01crural PVpralcct.) <br /> 1, FACiLiTY INFORMATION <br /> I, <br /> – <br /> �. <br /> RI ISINF,5I.NANJ1.7(snlrren%I:A(IIJTYN.kmr.nrn6A l,Ndnl:ln�inesxAxl <br /> Mantecsl Valero ryl. <br /> I+p. CITY <br /> Fl.lRINl1„S�';RI1'P,n1)nr:ll`+S <br /> 1001 E. `Yosemite Manteca,CA 95336 <br /> 11, INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> ARllk <br /> 7W10-1,RK�\I,JTI-i{JRIlrl.)I,INI7ER PT.i[;MIT <br /> I'YPI1OI+PRf)!r C"r(Choi+all l _ILLI mber lir ilmtcl: <br /> 1."I"A. 1K INSTALLATON()R RrPi.ACLMifNT <br /> �J 2,PiPiNC,TNSTA11 ATION OR RkF1,AC;MFN1" <br /> 3.s(ll+.gr'INWI'ALLATION OR RRPi ACTMIs"sNl" gR005624$ <br /> ❑ 4.1.,iN})ER msPr:NSItR(''0N'rAINN11',N'I'TNATALLA`rION Ok Ith,PLAC T MGNT <br /> TaT?,tiC'1t1P'I1teN f.'rl'WC1P,k rslilN(�c.�hit'I'1r�Ih.D: <br /> Replace'.d MLLD at$7 STP (new LLD SEI #08121049). <br /> Confirmi,-d operability with EHD inspector on site 6JAN2009. <br /> —F If), CONTRACTOR INFORMATION <br /> NAMF OS--CONTRAZTOR W1 10 PI FORMI'D INSTA1,1.A'T ION 1 M013111CA'rl(1N <br /> Henderson Maintenance Company <br /> d71as. <br /> COMA/;C'TOR l,1(lN+1.11 <br /> rC�C.cr.R'rrF1CA,nc.)N 11 <br /> 8567711 8016288-UT <br /> – IV.CERTIFICATION <br /> l Ct'rtif;!'that the inrormal:ion provided herein is true,accurate,and that the followiing earnditious have been satisfied- <br /> * Thi;:installer has met the mquirctnents set forth in 23 C'C'lt X2715,subdivisions(g)and(h). <br /> • Thar. underground sterage tank, any primary piping,, alt(1 any secondary cotltainment Was installed according to applicable <br /> vnl`:intvy conscnsus stand irds and any inanufbcturcr's Written instalkition instructions. <br /> • all Work listed in the manufacttrrer's installation chce*list has been completed. <br /> ■ Tlu installation 11111 licca inspected slid approvcd by the local agency,lir•if required by the local 1�enay, inspected and cert`sfied <br /> h a registered profollsional engincer having education and ex erience with underground story c tank s stem installations, <br /> !il(9NA'I'.1Rlf{7#''I`AN'f)WN=R <br /> OR(YWNIa(`;;J1tjI;NT IJA'1'I?. <br /> axa. PNONC <br /> y� 1199109 ^( 209 } 467.7573 <br /> .. ..�--- -- <br /> CF..R'rIFli;R'S NAME;fgrinl1 75 r I Il I IVS'1'iTi.r: <br /> Carl W Henderson Owner-Henderson Maintenance Company_ <br /> NAME(.IT T IM 11.OY r'.R(DBA) <br /> 'IM C?R'r-Irrrrrt'S Rrr.A•rION5141P r(, TANK OWNER <br /> Hender,on Maintenance Company Ej i TAMC OWNER ❑ 2.TANK OPERATOR <br /> �( 3,CONTRACTOR 4,PROPESR'1'Y OWNFR <br /> I © S.OTi-IGRAU-1"I-IC)R17.r'T)ACPNTOFi`ANICOWNT2R <br /> Rev.(12/2007) <br />