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07/27/2010 12:45 209-465-4988 HMC I SST PAGE 01/01 <br /> UNIFIED PROGRAM CONSOLIDATED FORM JUL <br /> UNDERGROUND STORAGE TANK , 72010 <br /> CERTIFICATION OF INSTALLATION /MODIFICATION, <br /> _One forth.prF.project.) <br /> I. FACILITY INFORMATION Ti <br /> 1. <br /> FACILITY ID#(Agency Use Only) <br /> 3. <br /> BUSINESS NAME(Sarno as FACILMY NAME or DBA—Doing ausincss As) <br /> ARCO-Manteca <br /> BUSINESS SITE ADDRESS 103. CITY 11N. <br /> 1100 S Main Manteca, CA 95337 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that avoly) 4831 WORK AUTHORIZED UNDER PERMIT +sib. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SR0059038 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ® <br /> 5.OTHER 4x3c <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Certified sensors, probes and 87 MLLD operability with EHD inspector on site. <br /> 111. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> Henderson Maintenance Company <br /> asz <br /> 482.. ICC CERTIFICATION482c.CONTRACTOR LICENSE-# <br /> 856771 8016288-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 /> boy a registered professional engineer having education and ex erience with underground storage tanks stem installations. <br /> ;SIGN TURF F K OWNER OR OWNER'S AGENT DATE 48s. PHONE 481. <br /> 7/27/10 ( 209 ) 467-7573 <br /> 411 <br /> RTIFIER'S NAME(print) CERTIFIER'S TITLE: <br /> Gavin Williams Technician <br /> ass CERTIFIER'S RELATIONSHIP TO TANK OWNER 48�' <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) <br /> Henderson Maintenance Company ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ® S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(12/2007) <br />