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iV,1Vcrcvvo I I ,4s t-AA Z"nf (buqu x,,,1001/001 <br /> 7NiF7 D PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY IN OAMA'I'TON <br /> FACILITY ID#(4gency Lfse Only) <br /> BUSINESS NAME(Santa o�Fociliey Nome or L)8,4Doing Busineyr ds) <br /> CRUISERS MANTECA#29 <br /> BUSINESS SlT ADDRESS CITY 104 <br /> 1137 W, LATIiROF RD, MANTECA, CA. 95336 <br /> IC, INSTALLATION/•.I QDIFICATION PROJFCI']DESCFMMON <br /> 7YPE.OFPROJECT(Checkgf(-dhayavy 481' WORKQUTIdORTlEDUNDERPERivfIT cab <br /> 21 1.TANK INSTALLATION Ott REPLACEMENT (Number or Date): <br /> 2.PINNO INSTALLATION alt REPLACE AENr <br /> 3,SUMP INSTALLATION OR REPLACFMENT <br /> ER 4.UNDER DISPENSER CONTAINMENT 1NSTALLATIQN OR REPLACEMENT S Q,OOS'?Z�Z Awz,. tZi 2-ct� j <br /> S.OTHER <br /> DPgCRU'TION 0 WORK BEING C6 T1FML): .BIC <br /> 1, <br /> 20,40co y.�l Z451:::� . (-TA os 15 LH 0) <br /> ID tp I -t-d c�1 N1p Q s <br /> M. CONTRACTOR r"ORMATION <br /> NAME Of CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION ,Bap <br /> StEV-VIC E'S <br /> CONTRACTOR LICTNSE II 'B' ICC CERTIFICATION 0 4t2,. <br /> `7 79 �-� 6 25' -2 7 Co <br /> W. C)ERTNICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have Keen satisfied: <br /> • The installer has tnet the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). ` <br /> e The underground storage tank, any primary piping, and any secondary concainment was installed according to applicable <br /> I 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 inspeetod and approved by the local agency, or if required by the local agency, inspcoted and certified <br /> ty a registered Professiotial ea ineer having education and a erience with under ound stora a tanks ern installations. <br /> 51GNATURE OF TANK OWNER OR OWNER'S AGENT DATE sea. PH NE u� <br /> ro <br /> CERTIF�.R'S NAME Oviat) aes CSRTIFIBR'S TITLE: <Be <br /> NAME OF CERTIPIER'S EMPIAYEI�(DBA) 'g CERTIFIER'S RELATIONSHIP TO TANK OWNER cev <br /> ❑ 1,TANK OWNER El2.TANK OPERATOR <br /> LC �Vt^ 3.CONTRACTOR © 4.PROPERTY OWNER <br /> �+ J ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rcv.(12/2007)-1/I www.unidocs,wg <br />