Laserfiche WebLink
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) 1 <br /> BUSINESS NAME(Same u FACILT'NAME or DBA-Doing Business As) 3. <br /> 76-Lodi <br /> BUSINESS SITE ADDRESS 103 1 CITY 1N_ <br /> 1111 E Kettleman Ln Lodi, CA 95240 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 4U& WORK AUTHORIZED UNDER PERMIT 483b <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT 0058478 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ® 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4B3c <br /> Replaced ECPL12 and software at TLS-350. Programmed and Certified operability with EHD Inspector on site. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482. <br /> Henderson Maintenance Company <br /> CONTRACTOR LICENSE# 4836. ICC CERTIFICATION# 482. <br /> 856771 8016684-UT <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 /> SIGNATURE OF TANK WNER OR OWNER'S AGENT DATE 4M- PHONE 487. <br /> 4 11/7/09 ( 209 ) 467-7573 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: Ore. <br /> Carl W Henderson Contractor <br /> NAME OF CERTI FIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 48A <br /> Henderson Maintenance Company ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> 5d 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />