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4RUD PROGRAM CONSOLIDATED FO <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 />1 <br />d <br />i <br />BUSINESS NAME (Same as FAciLrrY NAME or DBA — Doing Business As) 3. <br />7-Eleven S# 19976 <br />BUSINESS SITE ADDRESS 103. <br />CITY 104 <br />1399 N. Main Street <br />Manteca <br />U. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that anolvl 483a. <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />X 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />SR0059184, February 2010 <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />❑ 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483 <br />Replace cracked 87 product "tee" fitting in Dispenser # 3-4. <br />Replace the 87 mechanical line leak detector. <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482x. <br />Walton Engineering, Inc. <br />CONTRACTOR LICENSE # 482b. <br />C CERTIFICATION # 482c. <br />2 8R <br />617238 <br />YL <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 bee spected and approved by the local agency, or if required by the local agency, inspected and certified <br />by a registeredprofess' al engineer having education and ex erience with underground storage tank system installations. <br />WNA F TANK2,�OR OWNER'S AGENT <br />DA 3 484. <br />PHONE 487. <br />(z <br />(916) 372-1888 <br />RTIFIER'S NAME (print) 485 <br />CERTIFIER'S TITLE: 486, <br />Sca# Me- <br />Contractor <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 469. <br />Walton Engineering, Inc. <br />❑ 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 -1/2 Rev. (12/2007) <br />