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0 • <br /> 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) I HA I H I I I t• <br /> BUSINESS NAME(Same as FACILMY NAME or DBA Doing Busmess As) 3' <br /> 7-Eleven #14117 <br /> BUSINESS SITE ADDRESS 103. CITY 104• <br /> 2725 Country Club 'Lane I Stockton <br /> II. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 493., WORK AUTHORIZED UNDER PERMIT 483n. <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 <br /> X 5,OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 433c <br /> Installation of new Veeder-Root Sump sensors #794380-208, to replace the damaged 352 sensors. <br /> Replaced and installed 208 sensors in the 91 and 87 STP sumps. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRAC'T'OR WHO PERFORMED INSTALLATION 1 MODIFICATION 420. <br /> Walton Engineering, Inc. <br /> CONTRACTOR LICENSE# � ICC CERTIFICATION# Me. <br /> 617238 5243762-U1 <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 stora a tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484 PHONE 497, <br /> 2 7 7 ,d (916) 463-6776 <br /> CERTIFIER'S NAME(print) 48s CERTIHER'S TITLE: 48e. <br /> Ian Moorhead Compliance Manager <br /> NAME OFCERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> 7-Eleven Inc. 0 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST•C•t/2 Rev.(1212007) <br />