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F-1 <br />FIED PROGRAM CONSOLIDATED FOR <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One font per' project) <br />L FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />1. <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3. <br />Shell <br />BUSINESS SITE ADDRESS 103 -CITY <br />104. <br />2320 EI Dorado Rd <br />Stockton, CA <br />H. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that apply l 483x. <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />4-27-09 SR0056769 <br />5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483e <br />Cold Start Monitor Certification <br />4-27-09 11:00a Tested all Sensors and Sensor Out. <br />Test all Electronic Line Leak Detector and Fail Safe. <br />All Tests Passed and confirmed operational. <br />V91 :9,315-00-3600 <br />HL CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a. <br />Gavin Williams <br />CONTRACTOR LICENSE # 482b. <br />ICC CERTIFICATION # 4820. <br />856771 <br />8016288 -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 r. ce with underground storage tanks stem installations. <br />SIG rIJRE OF TANK OWNER OR OWNER'S AGENT <br />DATE 484. <br />PHONE 487. <br />- -=a <br />4/27/09 <br />1 ( 209 ) 943-1311 <br />CER IER'S NAME (print) 483 <br />CERTIFIER'S TITLE: 486. <br />Gavin Williams <br />Technician <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />HMC -Henderson Maint Co. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />® 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C -1/2 Rev. (12/2007) <br />