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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(Ore form per project.) <br />1. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />1' <br />BUSINESS NAME (same= FAciLrrY NAME w DBA— Doing Business As) 3. <br />COS Municipal Service Center <br />BUSINESS SITE ADDRESS 103. <br />CITY 1(A. <br />1465 S Lincoln St <br />Stockton, CA <br />II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check 1fl that 1M1X) 483a <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />SR0065598 10-05-2012 <br />® 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483e <br />Replaced boot under #7/8. <br />Cleaned & sealed penetrations under #5/6. <br />�JA <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION 1 MODIFICATION 482a <br />Service Station Testing - SST, Inc <br />CONTRACTOR LICENSE # 482b. <br />ICC CERTIFICATION # 432,- <br />962520 <br />5252923 <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 havi education and ex erience with underground stor a tanksystem installations. <br />SIGNATURE OF TANKQWN�t OR OWNER'S AGENT <br />DATE 484. <br />PHONE 487. <br />t� l�G� ----- <br />5-15-2013 <br />1 <br />( 209 ) 465-5577 <br />CERTIFIER'S NAME (print) 485 <br />CERTIFIER'S TITLE: ate. <br />Carl W Henderson <br />President <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />Service STation Testint - SST, Inc <br />❑ L TANK OWNER ❑ 2. TANK OPERATOR <br />® 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C -1/2 Rev. (1212007) <br />