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IED PROGRAM CONSOLIDATED F <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> E: (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency use Only) I' <br /> BUSINESS NAME(Same u FACn.n Y NA AE a DBA-Doing au inen As) 3' <br /> Tower#886 <br /> BUSINESS SITE ADDRESS 103 1 CITY 100- <br /> 1434 W. Yosemite Avenue Manteca <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aDoly) 483&. WORK AUTHORIZED UNDER PERMIT 4836. <br /> ❑ L 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: 483c <br /> Replaced and tested the 91 MLLD, Vaporless, LD2000) during annual compliance testing. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a� <br /> Walton Engineering, Inc. <br /> CONTRACTOR LICENSE# 4826. ICC CERTIFICATION# Mc2 <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(b). <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 ATU OF TANK OWNER OR OWNER'S AGENT DATE 484, 1 PHONE 487. <br /> 1-4-10 (916) 372-1888 <br /> CER IE S NAME(print) 485 CERTIFIER'S TITLE: <br /> Jes 'e adkins Tech <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> Walton Engineering, Inc. ❑ I,TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> X 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-12 Rev.(12/2007) <br />