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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> =CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID # (Agency Use Only) 1177"TF <br /> BUSINESS NAME (Same w FACUM NAME orDBA — DoingBurness As) <br /> Arco AMPM <br /> BUSINESS SITE ADDRESS 303. CITY iO4 <br /> 800 E Kettleman Lane Lodi <br /> II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br /> E OF PROJECT (Check all that annly) 463& WORK AUTHORIZED UNDER PERMIT 463e. <br /> I . TANK INSTALLATION OR REPLACEMENT (Number or Date) : <br /> . PIPING INSTALLATION OR REPLACEMENT SR0078236 <br /> SUMP INSTALLATION OR REPLACEMENT <br /> 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5a OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4B3c <br /> Installation of 2 USTs <br /> Eight Dispenser with UDCs <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 462& <br /> Town & Country Contractors, Inc <br /> CONTRACTOR LICENSE # 462n. ICC CERTIFICATION # 482e. <br /> 238112 5275557 <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 /> O 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 ex erience with underground storage tank system installations . <br /> SIGNATURE OF TA17 <br /> OWNER OR OWNER'S AGENT DATE 484• PHONE 487, <br /> CL 11 -22- 19 ( 916 636 -9500 <br /> CERTIFIER' S NAMEprint) 485 CERTIFIER' S TITLE: 466• <br /> Miguel Ceja Field Superintendent <br /> NAME OF CERTIFIEWS EMPLOYER (DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 469. <br /> ElsI . TANK OWNER ❑ 2 . TANK OPERATOR <br /> 3. CON'T'RACTOR ❑ 4. PROPERTY OWNER <br /> ❑ <br /> 5 , OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C - 1/2 Rev. (12/2007) <br />