COMPLIANCE INFO_2008-2012 - Laserfiche WebLink

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FIED PROGRAM CONSOLIDATED FOM, �� C/ �D UNDERGROUND STORAGE TANK D CERTIFICATION OF INSTALLATION/ MODIFICAU (One form project.) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) MV IV' IVI Iml lL L171. fT; ER I BUSINESS NAME(same as FACILITY NAME or DBA—Doing Business As) 3. Quik Stop #144 BUSINESS SITE ADDRESS 103. CITY 104. 7272 West Lane Stockton II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT(Check all that apply l Ossa. WORK AUTHORIZED UNDER PERMIT 483b. ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2.PIPING INSTALLATION OR REPLACEMENT ❑ 3.SUMP INSTALLATION OR REPLACEMENT ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT X 5.OTHER DESCRIPTION OF WORK BEING CERTIFIED: 483 The 89 MLLD failed during the annual Monitoring Certification Testing on August 10,2009. Replaced and retested with inspector present. Required permit submitted for on 8-21-09 for the Veeder-Root VM199LD-2000 Line Leak detector replacement. III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. Walton Engineering, Inc. CONTRACTOR LICENSE# 412b. ICC CERTIFICATION# 482`. 617238 5243762-U1 IV.CERTIFICATION I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable voluntary consensus standards and any manufacturer's written installation instructions. • All work listed in the manufacturer's installation checklist has been completed. • The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified by a registered professional engineer having education and ex erience with underground storage tank system installations. SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484, PHONE 487. 9-10-09 (916) 372-1888 CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. Dulcinea Webb Contractor NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489, Walton Engineering, Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER X 5.OTHER AUTHORIZED AGENT OF TANK OWNER UPCF UST-C-1/2 Rev.(12/2007)