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zC <br /> n <br /> il, <br /> UNIFIED PROGRAM CONSOLIDATED FORM 0 2 <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFIgA f), �J 1- <br /> Ili(bne Yorm gerr`oec <br /> I. FACILITY INFORMATION <br /> FACILI'T'Y ID€I(Agency Use Onl}) I. <br /> TTT 1 <br /> BUSINESS NAME(Same as FACILITY NAvff or DBA-Doing Business As) 3. <br /> Pilot Flying J 618 <br /> BUSINESS SITE ADDRESS Ins. CITY �� <br /> Eipon, CA. <br /> III. INSTALLATION/ ODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROTECT(Check all that Mul 413a. WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ T.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT 05-01-17 <br /> (� S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> L20 UDC 14/15 794380-208 sensor was replaced due to sensor out alarm. <br /> Tested sensor after repair and checked out okay. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. <br /> Daniel Marroquin <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 482c- <br /> 804431 8185785 V B42621 <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 e erience with under round stora e tank system installations. <br /> SI AT O K OWNER OR OWNER'S AGENT DATE nsa, PHONE 487. <br /> -1-17 { 585 ) 972-7581 <br /> CERTIFIERS NAME(print) 48' CERTIFIEWS TITLE: 436, <br /> Daniel Marroquin Service Technician <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIFR'S RELATIONSHIP TO TANK OWNER 489, <br /> 17711.TANK OWNER ❑ 2.TANK OPERATOR <br /> Jones Covey roup R 3.CONTRACTOR ❑ 4.PROPERTY OIANER <br /> Q 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UFCF LIST-C-112 Rev.(12/2607) <br />