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FIED PROGRAM CONSOLIDATED FO _. UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION /MODIFICATION (One form per project.) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(same as FACBdTY NAME or DBA—Doing Business As) 3. CRLLC#5446 BUSINESS SITE ADDRESS 103. CITY 104. 1403 Country Club Boulevard Stockton H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT(Check all that annlvl 483.. WORK AUTHORIZED UNDER PERMIT 483b. ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2.PIPING INSTALLATION OR REPLACEMENT ❑ 3.SUMP INSTALLATION OR REPLACEMENT SR# 0059964, May 2010 ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT XX 5.OTHER DESCRIPTION OF WORK BEING CERTIFIED: 4830 Replace the 87 product direct-bury OPW 5 gal spill container, and repair the float & chain assembly in Disp #1/2 UDC. III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. Walton Engineering, Inc. CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 482` 617238 i 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 WNER'S AGENT DATE 484. PHONE 482 �/ (916) 372-1888 ERTIFIER' AME(print) 485 CERTIFIER'S TITLE: ase. ,1 j;