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l ..IFIED PROGRAM CONSOLIDATED FOV <br /> Hca UNDERGROUND STORAGE TANK <br /> %RTIFICATION OF INSTALLATION /MODIFICATION <br /> \j R (One form per project) <br /> `1'c>.' `` c'' I. FACILITY INFORMATION <br /> FACILITY m#(Agency Use Only) I. <br /> BUSINESS NAME(Same as Facility Nume or DBA—Doing Business As) 3, <br /> Pacific Gas and Electric Company-Stockton Service Center <br /> BUSINESS SITE ADDRESS 107. CITY IN. <br /> 4040 West Lane Stockton <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a 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 .S'R0053265 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ® 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br /> Replaced the aboveground piping and spill containment for the remote used oil fill in the garage shop. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> John Sutfin-Su erior Underground Tank Service <br /> CONTRACTOR LICENSE# 482n. ICC CERTIFICATION# 482c. <br /> 482356 A, B, C21, C27, HAZ 5254957-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 /> I 4y a registered professional engineer having education and ex erience with underground storage tanks stem installations. <br /> SIG URE <br /> RF.OF TAN WNER OR OWNER'S AGENT DATE 494. PHONE 48T.4/24/2008 (925) 519-7887 <br /> CER I 'NAME(prino 485. CERTIFIER'S"TITLE: 486' <br /> John W. Sutfin Petroleum System Contractor <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489, <br /> Superior Underground Tank Service dba SUTS ❑ L TANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007).1/2 w .unidocs.org <br />