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SM -47/07/2010 09:59 <br />I I 'g.. �1j <br />209-465-4988 HMC / SST PAGE 01/01 <br />JUL 0 7 2010 UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />SAIN JOi%f OF INSTALLATION / MODIFICATION <br />-;,,j COUAWRTIFICATION <br />(one form per project.) <br />E N V C, `.'N IN TA L <br />I. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />3. <br />BUSINESS NAME (Same as FACIUN NAME 1), DBA - DoinSBusinos AS) <br />Shell - Stockton <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />2320 N El Dorado <br />1 <br />Stockton, CA 95209 <br />11. INSTALLATION t MODIFICATION PROJECT DESCRIPTION <br />4830. WORK AUTHORIZED UNDER PERMIT 483b. <br />TYPE OF PROJECT (Check ailthat <br />[:] 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): <br />E] 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT SR0060350 <br />4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />HI 5. OTHER —483C <br />DESCRIPTION OF WORK BEING CERTIFIED: <br />Replace L-4 annular space sensor. <br />Veeder-Root 794380-302 <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION 4812m <br />Henderson Maintenance Company <br />CONTRACTOR LICENSE# 482b' <br />I ICC CERTIFICATION # 482 C. <br />856771 <br />5252923 -UT <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 rience with undearound storage tank system installations. <br />SIGNATURE OF TANK O"EF ,UK OWNER'S AGENT DATE 484. PHONE 497. <br />717/10 209 ) 467-7573 <br />1 <br />CERTIFIER'S NAME (print) CERTIFIER'S TITLE: <br />Technician <br />Carl Wayne Henderson4 . <br />489. <br />88 <br />NAME OF CERTIFIER'S EMPLOYER (DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER <br />Henderson Maintenance Company ❑ 1, TANK OWNER [:1 2. TANK OPERATOR <br />JZ 3. CONTRACTOR [J 4. PROPERTY OWNER <br />[] 5. OTHER AUTHORIZED AGENT Of TANK OWNER <br />UPCF UST -C - 1/2 Rev. (12/2007) <br />