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12/19/2008 07:40 FAX 825772 MANTECA SHELL Z005 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NA (Sams as Fx1thy Name or DBA-Doing Badness AV t' <br /> Manteca Shell <br /> BUSINESS SITE ADDRESS tai. 1 CITY IN, <br /> 824 E Yosemite Ave Manteca <br /> II. INSTALLATION/MOTIIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROIECT(Cheek an that aaaN) 111L WORK AUTHORIZED UNDER PERMIT <•3h. <br /> ❑ L TANK INSTALLATION OR REPLACEMENT (Number or Date: <br /> ❑ 2.PIPING INSTALLATION OR REPLACHMENT 0/23108 <br /> ❑ 3.SUMP INSTALLATION OR RBPLACEMENT te <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT sic a 3 ry <br /> R=5.07'ElbR <br /> OP WORK BRING CERTIFIED: e89w <br /> �,eaV OFlle-40r Va Pb HFfs 179u -Zry much A"-cell L. e .e tk ocpec�i- <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION e°r` <br /> CONTRACTOR LICENsB 0 4121' ICC CERTIFICATION k 4M. <br /> 3a z -u <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 /> b aregistered professional engineer hav' education and erience with underground storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE FHONE <br /> 4/29/2008 (209) 825-7722 <br /> CERTIFIER'S NAME(print) CBRTIFIER'S TITLE: ' <br /> seung y Ilur Owner <br /> NAME OF CERTIFIBR'S EMPLOYER(DBA) Bt' CEIITIPIER'S RELATIONSHIP TO TANK OWNER �. <br /> VT-j L Ir't, l h N{Ml IM 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> El3.CONTRACTOR ❑ 4,PROPERTY OWNER <br /> 9 PIC <br /> I I C ❑ 5,OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(1L2007)-1/2 www,unldae.ors <br />