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FIED PROGRAM CONSOLIDATED FOIWN <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One forth per project.) <br /> FACL FACILITY INFORMATION <br /> ILITY ID#(Agency Use Only) <br /> BUSINESS NAME(same asFAcn.3rY NANs«oaA-novae auvaa,a Ae) <br /> Fast Lane Gas Lathro <br /> BUSINESS SITE ADDRESS 103. <br /> CITY <br /> 116 E. Roth Road <br /> Lathrop <br /> H. ]INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check ell that en 1 413e <br /> ❑ <br /> I.TANK INSTALLATION OR REPLACEMENT WORK AUTHORIZED UNDER PERMIT 4836. <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> Cl 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> X 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Replace the 87 STP sump senaw and retealerJ483c. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> Walton Engineering, Inc. 482a. <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 482c. <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 /> b are istered rofessional en ineer havin education and a erience with underground Stora a tack system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 4s4 <br /> PHONE 4s7. <br /> (916) 372-1888 <br /> CERT R'S <br /> NAME(print) 485 CERTIFIER'S TffLE: 4as. <br /> Contractor <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 4as CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> Walton Engineering, Inc. ❑ ,.TANKOWNER �9 <br /> ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> X 5,OTHER AUTHORIZED <br /> 'OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(12/2007) <br />