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01/26/2010 14:54 209-465-4988 HMC PAGE 01/01 <br /> .e <br /> UNRFM PROGRAM CONSOLIDATED FORM ' <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION®F INSTALLATION®MODIFICATION L&,:6 <br /> L FACILITY INFORMATION SAN ')i, ;e <br /> FACILITY ID#(AgencyUse Only) <br /> BUSINESS NAME(Smoot FAcuSrYXAMEorDttA—Dong A,) <br /> Quik Shop <br /> ]BUSaJESS SITE ADDRESS 103• CITY 104. <br /> 2072 W.Yosemite Ave Manteca, CA <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aunlvl ma. WORK AUTEIomm UNDER PERMIT 4W& <br /> ® I.TANK INSTALLATION OR REPLACENENT (Nater or Dam): <br /> ❑ z PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATFONORREPLACEIMENT SR005M2 <br /> ® 4 UNDER DISPENSER CONTA(iV1 ENT INSTALLATION OR <br /> KI 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTOWD: 4c <br /> 87 Leak Detector was replaced prior to Scheduled Visit with EHD. <br /> 1-19-10 3:00p Tested 87 ML-D with EHD Inspector 87 Line Leak Detector Passed 3.0 GPH Test.Checked operation. <br /> 1IL CONTRACTOR INFORMATION <br /> NAM&OF CONTRACTOR WHO PERFORNM INSTALLATION/MODIFICATION 4 <br /> Gavin Williams <br /> CONTRACTOR LICENSE# 4ffi1, 1 ICC CERTIFICATION# 4M. <br /> 856771 8016684-UT <br /> IV.CERTIFICATION <br /> I certify that the information provided herein is tree,aceaarate,and that the following conditions have been satisfied: <br /> • The installer has met the requirements set forth in 23 CCR§27I5,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 manufach»r's vvlitten installation instructions. <br /> • All work listed in the manufacturer's instaUatioa 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 /> b are ' fessional engineer education and with storage tank installations. <br /> SIGNA OF WNERAW OWNERS AGENT DATE 4aa JPHONE 4P• <br /> _ v19110 ( ) <br /> CERTUMR'S NAME(print) 483 CERTIFFIER'S TITLE: 486. <br /> Gavin Williams Tech <br /> NAM&OF CERTIFIERS EMPLOYER(DBA) 4wCRtT*WR'S RELATIONSHIPTO TANK OWNER 4N. <br /> HMC-Henderson Maintenance Company ® LTANK OWNER ❑ Z TANK OPERATOR <br /> ❑ 1 CONTRACTOR p 4 PROPERTY OWNER <br /> ® S.OTI•MAUTHOP.VMAGENTOFTANKOWNER <br /> UPCF UST-C-in Rev.(1=007) <br />