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41FIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agencv Ilse Only <br /> i. <br /> BI I 1 —1 11777 L[ <br /> USINESS NAME(Same as Facility Name or DBA—Doing Business As) <br /> 3. <br /> MAIN STREET ARCO AM/PM <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 1100 S. Main Street Manteca CA. 95336 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all thatappW 4839- WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SR0055393 <br /> El 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> aaTc. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482y <br /> Reliable Petroleum Services Inc. / Robert Barnhart <br /> CONTRACTOR LICENSE# as'b. ICC CERTIFICATION# 4R2c <br /> 883706 52522540 UI <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 experience with underground stora a tanks stem installations. <br /> SIGNATURE OF K OWNER OR OWNER'S AGENT DATE 484. PHONE 487 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ,;�'2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidoes.org <br />