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POWFIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One Form per project) <br /> L FACILITY INFORMATION <br /> FACILITY M#(Agency Use Only) <br /> 3. <br /> BUSINESS NAME(Sane.FAmnY NAME w OHA-coins B,.9 eAs) <br /> Wine Country Station <br /> BUSINESS SITE ADDRESS 103 CITY <br /> 1111 E. Kettleman Lane Lodi <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aooly) 40' WORK AUTHORIZED UNDER PERMIT 03b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SR0055729 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4836 <br /> Installation of a new (87) annular sensor and retest. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CON'T'RACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4� <br /> Walton Engineering, Inc. <br /> CONTRACTOR LICENSE# ICC CERTIFICATION# <br /> 617238 5307886=ttT !�zy 90 Z -- L� t <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 Pence with undergound storage tanks stem installations. <br /> SIG URE OF WNER OR OWNER'S AGENT DATE aa4I PHONE ' 7 <br /> t_i- �Cti 11-20-08 (916) 372-1888 <br /> CERTIFIER'S NAME(print) CERTIFIER'S TITLE: <br /> Bruce Stewart Technician <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) °88 CERTIFIER'S RELATIONSHIP TO TANK OWNER 4119 <br /> WaltonEngineering, 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!1007) <br />