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IED PROGRAM CONSOLIDATED FOtCd <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same u FACH=NAME or DBA—Doi,,Business As) 3. <br /> Circle K#2701205 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 16470 Cambridge Drive Lathrop <br /> IL INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that auDly) 413e. WORK AUTHORIZED UNDER PERMIT °sib. <br /> ❑ L 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 <br /> DESCRIPTION OF WORK BEING CERTIFIED: 48R <br /> Replaced the 87 MLLD. Vaporless VMI LD-2000. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. <br /> Walton Engineering, Inc. <br /> CONTRACTOR LICENSE# 4111. ICC CERTIFICATION# 412a. <br /> 617238 5243762-U1 <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 local agency, inspected and certified <br /> by aregistered professional engineer having education and ex erience with under ound storage tanks stem installations. <br /> SI ATURE OF TANK OWNER OR OWNER'S AGENT DATE 084, PHONE 487- <br /> �� r 2-01-11 (916) 373-1166 <br /> CERTIFIER'S NAME(print) 415 CERTIFIER'S TITLE: 416, <br /> Dulcinea Covan Compliance Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489, <br /> Walton Engineering, Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> X 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-12 Rev.(122007) <br />