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05/15/2009 10: 40 209-465-4988 HMC PAGE 01/01 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One forrn per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) E] <br /> BUSINESS NAME(Sume as FACILITY NAME or DBA-Doing Business As) 3. <br /> Waterloo Shell <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 4315 Waterloo Rd Stockton <br /> 11. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483'• 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 SR 0057244 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Replaced 91 STP sump sensor and certified operability. <br /> MAY 5 2009 <br /> SAN joAQ <br /> H ALTENV/q*Q A4EN7-AL ry <br /> E4CTy�EPA"TMENT <br /> 111. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482n. <br /> Henderson Maintenance Company <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 482c. <br /> 856771 5252923-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 stora a tanks stem installations. <br /> SIGNATURE OF TANK 4 <br /> WNER OR OWNER'S AGENT DATE 84, PHONE 487. <br /> 5/15/09 ( 209 ) 467-7573 <br /> CERTIFIER'S NAME(print) 486 CERTIFIER'S TITLE: 486. <br /> Carl W Henderson Owner <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> Henderson Maintenance Company ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> PO Box 31325 - Stockton, CA 95213 ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCt±UST-C-1/2 Rev.(12/2007) <br />