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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) d dI <br /> BUSINESS NAME(Same as FACILrrY NAME or DBA—Doing Business As) 3. <br /> 7-11 Site # 41216 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 770 Charter Way Stockton <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a. WORK AUTHORIZED UNDER PERMIT 483b. <br /> ® 1.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 B P20-02319 <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Remove & replace fuel system. This includes dispensers, piping and UST's. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> Wilkey's Construction, Inc. Dale Adams, Supervisor <br /> CONTRACTOR LICENSE# 482b' ICC CERTIFICATION# 482c' <br /> 722945 8188560 <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 ex erience with underground storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. <br /> Dale Adams Supervisor <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> Wilkey's Construction, Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />