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Ak RIECIENLnn <br /> UrIFIED PROGRAM CONSOLIDATED FOFW <br /> UNDERGROUND STORAGE TANK JAM 2 2 2010 <br /> CERTIFICATION OF INSTALLATION /MODIFIft*" � JeC1) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> 3 <br /> BUSINESS NAME(S—.u FACB.rrY NA .DBA—Doing Buai.,M) <br /> Tower#886 <br /> BUSINESS SITE ADDRESS iO3- CITY 104 <br /> 1434 W. Yosemite Avenue Manteca <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that anDly) 483-. WORK AUTHORIZED UNDER PERMIT 4536. <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 S.OTHER 493c <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Replaced and tested the 91 MLLD, Vaporless, 1-02000)during annual compliance testing. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482.. <br /> Walton Engineering, Inc. <br /> CONTRACTOR LICENSE# 4526. 48zc. <br /> ICC CERTIFICATION# <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 storage tanks stem installations. <br /> SIG AT OF TANK OWNER OR OWNER'S AGENT DATE 484, PHONE 487. <br /> 1-4-10 (916) 372-1888 <br /> CER IE S NAME(print) 485 CERTIFIER'S TITLE: 48e. <br /> Jes ie adkins Tech <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489, <br /> Walton Engineering, Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> X 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1B <br /> Rev.(12t2007) <br />