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05/15/2013 11:40 209-465-4988 HMC PAGE 01/01 <br />0 0 RECEIVED <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUNDSTORAGETANK <br />*_=rLTXV_xr_ 1012XI 401;k a 0L� t=am, # ii;_Li <br />UPCF UST -C - 112 Rev. (1212007) <br />I <br />-NMI <br />I. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />BUSINESS NAME (Same W FACILM NAME or DBA -Daft Businam AS) <br />COS Municipal Service Center <br />BUSINESS SITE ADDRESS <br />1465 S Lincoln St <br />Stockton, CA <br />II. INSTALLATION MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that WORK AUTHORIZED UNDER PERMIT 483h <br />E3 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT SR0065598 10-05-2012 <br />4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />El S. OTHER 4 <br />DESCRIPTION Of WORK BEING CERTIFIED: <br />Replaced boot under #7/8. <br />Cleaned & sealed penetrations under #5/6. <br />D <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHOPERFORMED INSTALLATION / MODIFICATION <br />Service Station Testing - SST, Inc <br />CONTRACTOR LICENSE # 48 <br />TCC CERTIFICATION # 482L <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 />bX a stered professional engineer having education and ex erience with under ound q2Mp tank system installations. <br />SIGNATURE OF TANK QWNfOR OR OWNERS AGENT <br />DATE 434. <br />PHONE 497. <br />5-15-2013 <br />(209 ) 465-5577 <br />CERTIFIER'S NAME (print) <br />CERTIFIER'S TITLE: 45M <br />Carl W Henderson <br />President <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 489 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 439, <br />Service STation Testint - SST, Inc <br />❑ 1. TANK OWNER 0 2. TANK OPERATOR <br />3. CONTRACTOR [1 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C - 112 Rev. (1212007) <br />I <br />