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UNHn"PROGRAM CONSOLEDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> :CE:R:T1FICATION OF INSTALLATION/MODIFICATION(One form pee p-ject) <br /> 0 1 <br /> L FACILITY INFORAL4,TION Mi <br /> F-Ct=i V r-Ij <br /> FACILITY ID#(Agency Use 0*) t. <br /> BUSINESS (SamewFACU,ITYRAMEmDBA-DowgBmA.) 3. <br /> Jim Thorpe Oil EMR110I-HEALTH <br /> BUSINESS SITE ADDRESS Y <br /> CIT OWMENI&PER MIT/SERVICE S <br /> 351 N. Beckman Rd. Lodi , CA 95240 <br /> 11 INSTALLATION MODMCATION PROJECT DESCRIPTION <br /> TYPE OF PROTECT(Cb=k all that awly) 481, WORK AUTHORIZED UNDER PEP--.ffT 493b. <br /> 0 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> 0 2.PIPING INSTALLATION OR REPLACEMENT <br /> 0 3.SUW INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Repair leak in tank #16 <br /> Clean, sandblast tanks #16 , #17 <br /> Epoxy line tanks #16, #17 <br /> III CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4na, <br /> NW Tank Lining and Inspection , Inc. <br /> CONTRACTOR LICENSE# 4111, 1 ICC CERTIFICATION# Mc. <br /> 879166 D-12 1060463—U1 <br /> .0 T CA <br /> ON <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 taik 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 ppofessional Maineer having education and ex fence with underground storage system installations. <br /> SIGNATURE OF TANK OWNER OR O AGENT DATE 4M-IPHONE 48T <br /> (209 ) 368-9381 <br /> CERTIFIER'S NAME(Print) us CERTIFIER'S TITLE: 4N, <br /> Ervin Rifenburcf, PE California Reg . Civil Engineer <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) Ff h J 4= 499.CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> 1.TANK OWNER 0 2.TANK OPERATOR <br /> 1(E <br /> �g yie r i 0 3.CONTRACTOR 4.PROPERTY OWNER <br /> 5.O AUTHORIZED AGENT OF TANK OWNER <br /> E <br /> A, Rev.(IV20n <br /> UPCF <br /> UST-C 1/2 <br /> I v I <br />