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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 /> I. <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same.FACILITY NAME o,DBA—Ming Businm As) <br /> Shell Oil Co. ,g°. <br /> BUSINESS SITE ADDRESS 103. CITY <br /> 3515 Na v Drive Stockton, CA 95203 <br /> :anp <br /> STALLATION/MODIFICATION PROJECT DESCRIPTION <br /> 483x. WORK AUTHORIZED UNDER PERMIT 483b. <br /> TYPE OF PROJECT(Check all tha1.TANK INSTALLATION OACEMENT (Number or Date): <br /> 2.PIPING INSTALLATION OACEMENTSR0065994 <br /> 3.SUMP INSTALLATION OACEMENT❑ 4.UNDER DISPENSER CONENT INSTALLATION OR REPLACEMENT <br /> ® 5.OTHER 483. <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Installed (2) 11x8.8x6.8x4.5A Icon Piping Penetrations Fittings, Sump 2 <br /> Installed (1) 3.5x1.6 Icon Electrical Piping Penetration Fitting, Sump 2 <br /> Installed (1) 6.8x4.5A Split Penetration, Sump 1 <br /> Secondary Containment Testing Passed 12/11/2012 <br /> III. CONTRACTOR INFORMATION <br /> 4820, <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> Tait Environmental Services, Inc. 48�,. <br /> 4am. ICC CERTIFICATION N <br /> CONTRACTOR LICENSE p <br /> 588098 5252163 <br /> IV.CERTIFICATION <br /> FeThefy that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> he installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). <br /> he underground storage tank, any primary piping, and any secondary containment was installed according to applicable <br /> oluntary consensus standards and any manufacturer's written installation instructions. <br /> ll work listed in the manufacturer's installation checklist has been completed. <br /> installation has been inspected and approved by the local agency,or if required by the local agency, inspected and certified <br /> b a re istered rofessional engineer havin education and experience with under round stora8e tanks tem installations. 4g <br /> 7. <br /> SIG TO OF TANK OWNER OR OWNER'S AGENT DATE PHONE <br /> 1/16/2013 (714) 920-8212 -486 <br /> 485 CERTIFIER'S TITLE: <br /> Erin Lan foordrd 1 9 <br /> IFIER' Project Manager <br /> 488 489. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> Tait Environmental Services, Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> Rev.(122007) <br /> UPCF UST-C-1/2 <br />