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0 BECEIV D <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK AY4 Zt <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> I. FACILITY INFOR.NIATION <br /> FACIL' i T Y ID r#(Agenxy Use On;v) I <br /> BUS IN ESS A%I%I,Sa-ie y FC:Ll i��NAtitE ar DGA-C-;6os:—di; 1. <br /> jCOS Municipal Service Center <br /> BUSINESS SITE ADDRESS 103. CITY � <br /> 1465 S Lincoln St Stockton, CA <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that anniv) 4937 WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> [12.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ® <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> REF: UST Inspection Report dated 4-16-2014: <br /> Item 303: Liquids removed and placed in drum on site. <br /> Item 310: Liquids removed and placed in drum on site. <br /> Inspection of UDC&Sumps will be performed quarterly to ensure sensor positioning and liquid status. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4927 <br /> Service Station Testing-SST,Inc <br /> CONTRACTOR LICENSE 411b. ICC CERTIFICATION# 4927 <br /> 962520 <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 erience With underground storage tank s stem installations. <br /> SIGNATURE OFTANK OrNEROR OWNER'S AGENT DATE 494• 1 PHONE 487. <br /> - — 4-18-2014 (209 ) 465-5577 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'STITLE: 4M <br /> Carl W Henderson President, Service Station Testing-SST, Inc <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489_ <br /> Service Station Testing-SST, Inc ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> PO Box 31465 - Stockton, CA 95213 ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />