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02/27/2009 20:26 2094654988 HMC PAqEY 01 / 01. h <br />UNIFIED PROGRAM CONSOLIDATED FORM 2009 <br />UNDERGROUND STORAGE TANK SAN <br />CERTIFICATION OF INSTALLATION / MODIFICX't'+L, �410UNTY <br />HEgi TH (0 M per protect.) <br />i. FACILITY INFORMATION <br />FACIL17 v 11) 01(ApencJ use Onlv) <br />SUSINEI,';S NAME (Anm nn PACILITI' NAMF or DOA - Doiniz Mminm M) <br />ARCO ,4M/°M <br />BUSINr-_$SS1rEADDRESS .qA, CTTY 104. <br />130S.1 NIL DON �STOCKTON <br />II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE 01 PROJECT (Chock all that apply) 'A36 <br />WORK AUTHORIZED UNDER PERMIT 4011. <br />1, TANK INSTALLATiON OR REPLACEMENT <br />(Number or Datc): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />© 3, SL MP INSTAi,T,ATTON OR RF;PT,ACF,MF,NT <br />SROO56484 <br />❑ 4. IRJDEF. DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />® 5, OTHER <br />— <br />DESCRJPTiO'v OF WORK B'E'ING CERTIFIED: 483C <br />REMON'(ED DEFECTIVE LEAK DETECTOR FROM MASTER STP, RELOCATE AND AND REPLACE PLLD FROM <br />SLAVE TO MASTER STP, INSTALL SWIFT CHECK. TESTED ON 2/27 AND PASSED OPERABILITY TEST. <br />iil. CONTR;\CTOR INFORMATION <br />NAMF, CF CONTRACTOR WHO PT!,RFORMED INSTALLATION /MODIFICATION <br />HEATH MCEVER <br />CONTRC,CTOR LICENSE It h'�' <br />icc CERTTFiCATiON # <br />856771 <br />5236756 -UT <br />iV. CERTIFICATION <br />i certif{r tllat the information provided herein is true, accurate, and that the following co- Jitions have been satisfied: <br />• Th• installer has met the requirements set Forth in 23 CCR §2715, subdivisions (g) and (h). <br />Th(:, 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 />• Th( installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by Gt re 'istere rofcssional cn ineer having education and ex erience with underground storage tank system installations. <br />STCINATI:IRT ANK OWNER OR OWNER'S AGENT <br />DATE °A° <br />PHONE 07.209 <br />) 467-7573 <br />CI RTII�'i;s NAME (print) °A' <br />CERTiFIER'S TiTLE: 446' <br />HEATH MCEVER <br />SERVICE TECHNICiAl' <br />CE•RTIFIER'S RELATiONSHI TO TANK OWNER 489. <br />NAME_ Ci' CERTiFIER'S EMPLOYER (T)BA) °NA <br />HMC- h ENDERSON MAINTENANCE COMPANY <br />❑ ].TANK OWNER d 2, TANK OPERATOR <br />3. CONTRACTOR [I A, PROPERTYOWNF.R <br />❑ 5, OTT -TER AUTI-TORT7F1) ACTFNT OF TANK OWNER <br />UPC,'F Ui T_(- - 1/2 Rev. (12/2007) <br />