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FROM : Don Iee pump co. <br />10/28/2008 TUE 12:58 <br />FAX NO. :2095379398 <br />FAX 2094683433 SJC LHO <br />8 07:11AN P2 <br />P"Et C �3Op0 / r1 l <br />OCT 2 8 2008 <br />UNIFIED PROGRAM CONSOLIDATED FORNI SAN JOAUUIN COUN'rY <br />UNDERGROUND STORAGE TANK EWRONMENTAL <br />CERTIFICATION OF INSTALLATION / MODIFIC A lyp -N DEPARTMENT <br />(Otte form per project) <br />1. FACILITY INFORMATION <br />FACILITY 11) # (Agerrcy Ure ate v) <br />I. <br />13t1S1NE39 NAMl: (Same as Fncillry NAma ar pelA - Ooilrg /3usb(ess Ax) �• I <br />I <br />ij Pfik <br />_._.1k`�14►s, <br />i S[ ES. Illi ADDR1 3S 101 13t1SINl.'.SS SITE CITY <br />1 <br />II. INSTA,LLA,TION / MODIFICATION PROJECT DESCRIPTION <br />1'YPI? QI' PR.O7L:CI' (Clrhek rd! rhn(av2yll} 1ej"' <br />WORK AITHORIZED UNDF,R PF.12Mi1 <br />0 L TANK INSTALLATION OR REPLACIimrwr <br />(Number or DAIc): <br />❑ 2. PIPING INSTAT,LNFION Olt RI_P1.ACE-HENT <br />❑ 3. SUMP INWI'ALLATION Olt REPLACEMPNT <br />❑ 4, UNDPR t)ISPI3NSIsR CON -1 AINMLNT INSTALLATION ort REPL.AamENT <br />9.0`ri1F1R <br />_ <br />U i.`1C:IURPION OF WORK BEINO CrRTIFIFD: 1R1r <br />I <br />Ve-e&r � 00 + '�'G►n IM��;,}e� Y`tt.�a �O�Ir^� G f6�� �a� <br />,.,.,........ ....... .._...w.--- - <br />III. CONTRACTOR INFORMATION <br />NAMr. 01' CONTRACT )R WI10 RRRFOR Mrn INSTAI,t.A'I'ION —/M-0—Dill ICATION M, <br />C <br />(`ONT'RA(JOR LICTI SL: k ICC: 0. ERTI 11CATION II <br />Lq 'S 3 Ur <br />------ <br />IV. CERTIFICATION <br />I certify that the information provided herein is true. accurate, and that the following conditions have been satlstied: <br />• The installer has met the requirements set forth in 23 CCR §27I5, subdivisions (g) and (h). <br />• The underground storage tank, any primary piping, and any secondary containment was installed according to applit:xhlo. <br />voluntary consensus standards and any manufacturer's written installation insu'nctions, <br />• All work listed in the IWILI acturer'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 ccrtified <br />by a registered profemional engineer havi ng education and ex erience with underground storage ranks stem installations. _ <br />SIGNATUR1: OF "I'ANK OWNPR Olt OWNER'S AGENT <br />TWIT; "° 4 <br />1'110NF 37 <br />W <br />N.\MIi UE CLk'I1141:1t'S rMPLbYIzR (I)BA) ids' <br />ca?R'1'[I°It:R'S RELATIONS] Ill' TO TANK OWNER r <br />(„] 1.'I'ANK C)WNE3R ❑ ? 'TANK OPERATOR <br />❑ 3. CONTRACTOR [14, PRnPEIi'rY OWNNR <br />i <br />2 S. UTHER AUTHOIU EI) AGLN:f 01: TAAiKOWNII <br />tJPCle UST -C Rev, (1222007) - 1/2 wwri.enidamorg <br />VIle- yo (11117/08 <br />