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IED PROGRAM CONSOLIDATED FORW UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION / MODIFICATION (One form per project.) I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1. rm BUSINESS NAME (Same as FACILITY NAME or DBA —Doing Business As) CRLLC# 2705447 BUSINESS SITE ADDRESS 103 CITY 704 146 E. Hammer Lane Stockton II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION PERMIT/SERVICES TYPE OF PROJECT (Check all that apply) 483a. WORK AUTHORIZED UNDER PERMIT 4836. ❑ 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2. PIPING INSTALLATION OR REPLACEMENT ❑ 3. SUMP INSTALLATION OR REPLACEMENT SR0062004 — 03/03/11 ❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT X 5. OTHER — SCT Repairs DESCRIPTION OF WORK BEING CERTIFIED: 483 Secondary Containment repairs on UDC #1/2, #7/8, #9/10 and the 91 product turbine sump. Repair the diesel STP relay and confirm positive shutdown. avc� qI PY,dvct 5CCU4 P )PitJ,- III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a. Walton Engineering, Inc. CONTRACTOR LICENSE # 4826. ICC CERTIFICATION # 482. 617238 j Zy (-9J<; 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 aregistered professional engineer having education and ex erience with underground stora a tank s stem installations. SIGNATURE OF TANK ER OR OWNER'S AGENT DATE 4g4. PHONE 487. — I�j — I , (916) 372-1888 CER R'S NAME print) 485 CERTIFIER'S TITLE: 486. 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)