Laserfiche WebLink
,- u <br /> I IFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> S P,-N <br /> TIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project.) <br /> E pEAM� I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3. <br /> QUIK STOP #152 <br /> BUSINESS SITE ADDRESS I03. CITY 104_ <br /> 1721 S. Cherokee Lane Lodi <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a. WORK AUTHORIZED UNDER PERMIT 483b, <br /> X 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT October 2012 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483a <br /> Installation of Bravo adapters at each of the two (2) UDCs <br /> Upgrade of existing (2) dispensers to Dresser Wayne Ovations <br /> Convert the existing 91 product UST to diesel product <br /> Convert the existing 89 product UST to 91 product <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. <br /> Walton Engineering, Inc. <br /> CONTRACTOR LICENSE# 482b" ICC CERTIFICATION# 482e. <br /> 617238 5216959 <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,4 registered professional engineer having education and ex erience with underground storage tanks stem installations. <br /> SIGN RE OF TAN R O ER'S AGENT DATE 484. PHONE 487. <br /> 10/12/12 (916) 372-1888 <br /> CE IFIER'S NAME(pri 485 CERTIFIER'S TITLE: 486. <br /> David Delgado Contractor <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> Walton Engineering, Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> X 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />