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209-465-4988 HMC PAGE 01/01 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project.) <br />1. FACILITY INFORMATION <br />FACILITY ID # (Agency use Only) <br />1' <br />BUSINESS NAME (Same O FACILITY NAME or DBA — Ooing Business AS) 3' <br />SHELL <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />2320 N EI Dorado <br />Stockton <br />11. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that VpW 483, <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />❑ i. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLA'T'ION OR REPLACEMENT <br />® 3. SUMP INSTALLATION OR REPLACEMENT <br />SR0058096 <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />® 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483c <br />Certified operation of 91 annular sensor. <br />8,1PpV <br />111. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a. <br />Heath McEver <br />CONTRACTOR LICENSE # 482b. <br />ICC CERTIFICATION # 482r. <br />856771 <br />15236756 -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 areisprofessional engineer having education and ex 'encs with under ound storage tank system installations. <br />OWNER OR OWNER'S AGENT <br />DATE 494 -PHONE <br />.187./ <br />SIGNATURANK <br />9/22/09( <br />209 } 465-4988 <br />ERTIFIER'S NAME (prim) 5 <br />CER IER'S TITLE: 4 ' <br />Heath McEver <br />Service Station Testing <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 4N <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 40' <br />HMC -Henderson Maintenance Company <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />® 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C -1/2 Rev. (1212007) <br />