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. IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION / MODIFICATION (One form per project.) I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1-7 BUSINESS NAME (Same ss FACILITY NAME or DBA - Doing Business As) 3. Quik Stop #148 BUSINESS SITE ADDRESS 103. CITY 104. 205 W. Lockeford Street Lodi H. INSTALLATION / MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT (Check all that ppplvl 413a. WORK AUTHORIZED UNDER PERMIT 483b. ❑ 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2. PIPING INSTALLATION OR REPLACEMENT ❑ 3. SUMP INSTALLATION OR REPLACEMENT ❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT X 5. OTHER DESCRIPTION OF WORK BEING CERTIFIED: 4830 Obtain the required permit for this work from the local COPA. Includes permit fee. Remove and dispose of the existing spill container. Furnish and install complete new OPW spill container. Provide and install new Face Seal adapters if required. Perform a "standing water" test in the spill container for CUPA inspection. Provide final test results to CUPA and Owner III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a. Walton Engineering, Inc. CONTRACTOR LICENSE # 4826. ICC CERTIFICATION # 482c. 617238 5243762-U1 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 a registered professional engineer having education and ex erience with underground storage tanks stem installations. SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. (916) 372-1888 CERTIFIER'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)