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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/ MODIFICATION <br /> (One form per project.) <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _ 1. <br /> BUS IN ESS NAME(Same us FACILITY NAME or DBA—Doing Business As) 3. <br /> LODI MEMORIAL HOSPITAL <br /> BUSINESS SITE ADDRESS 103, CITY 104- <br /> 975 SOUTH FAIRMOUNT AVE LODI <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 481x. 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 R 0 0 0 0 5 2 9 2 9 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT 1 / 28 / 08 <br /> 5.OTHER VENT/PRODUCT TRANSITION BOX INSTALLATION <br /> DESCRIPTION OF WORK BEING CERTIFIED: INSTALLATION O F 20 , 000 GALLON DW 483c <br /> DIESEL STORAGE TANK FOR BACK UP GENERATOR SYSTEM <br /> INCLUDING TANK/ PIPE SYSTEM CONTINUOUS MONITORING <br /> SYSTEM . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> WESTERN PUMP , INC . <br /> CONTRACTOR LICENSE# 4821. ICC CERTIFICATION# 4821. <br /> 673853 5246176 <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 /> by a registered professional engineer having education and ex erience with underground stora e tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484- /PHONE 487 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 436_ <br /> MICHAEL MIZICKO FIELD OPS MANAGER <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> WESTERN PUMP , INC . ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />