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09/04/2008 08:07 2094654988 <br />0 <br />HMC PAGE <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK SEP <br />4 2008 <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />SAN Aff)"910 ! proiect) <br />1. FACILITY INFORMATION NEALThI N ENTAL <br />DIZOA <br />FACILITY ID # r <br />(,4pitc <br />— y Use Only) i. <br />BUSINESS NAME (Snma rte rACILMY NAME or 015A — 00411- 8ushims As) <br />76 - Stockton "GATEWAY" <br />BUSINES.I.; SITE ADDKESS <br />322 S Center St <br />Stockton, CA 95203 <br />IL INSTALLATION MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that ngt11v1 4131, <br />WORK AUTHORIZED UNDER PERMIT 4HUX <br />C] 1. TANK rNSTALLATION OR REPLACEMENT <br />(NumLvr or Date)-. <br />2, PIPING INSTALLATION OR Rr7,PtAcr:,mFNT <br />3. SUMP INSTALLATION OR REPLACEMENT <br />C1 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPIACEMENT <br />SR0055203 Aust25,2008 <br />ug <br />Q 5, OTHRP <br />DRSCR IPTiiYN_0V WORK BEING CERTIFIED: Me <br />Replaced and certified 87 MLLD. <br />Ill. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORM151) INSTALLATION / MODIFICATION <br />HMC - Henderson Maintenance Company <br />CONTRACTOR LICENSE# <br />TCC CERTIFICATTON <br />856771 <br />8005932 -UT <br />IV. CERTIFICATION <br />I certify that the information provided herein is true, accurate, and that the following conditiobs 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 <br />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 kregistered profmional engineer having education and ex rience with underground stormue tank siystem installations. <br />GN/V - RE OF AN?KWNFR <br />Le 7 ,9R OWNER'S AGENT <br />DATE 4S4. <br />PHONE M. <br />A�e <br />9/4/08 <br />209 467-7573 <br />1 <br />�?oZiTrFiFIR'S NAME (print) / 496 <br />CERTIFIFR'S Ti—T17-- 496. <br />Joseph C Bridges <br />Service Technician <br />NAME OF CERTIFIER'S FMPLOVER(DBA) 40 <br />CERTTF1FR'S RELATIONSHIP TO TANK 0WNrA <br />HMC - Henderson Maintenance Company <br />0 T. TANK OWNER 171 2. TANK OPERATOR, <br />Z 3. CONTRACTOR 0 4, PROPERTY OWNER <br />El 5, OTFIFR AUTHORIZED AGENT Or TANK OWN8R <br />UPCF I IST -C -1/2 Rev. (12/2007) <br />