Laserfiche WebLink
01/14/ rjo 209-J-59-4988 HMC PAGE 01/01 <br /> R <br /> Z O O UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> EN RONMENT HEALk"TIFICATION OF INSTALLATION/MODIFICATION(One form per project.) <br /> L FACILITY INFORMATION <br /> 1. <br /> FAcml rY M H(Agency Use Only) _ — <br /> FT3. <br /> BUSINESS NAME(Sam,a,FACnZrY NAME or DEA—Doing BoaiM"As) <br /> Delta Arco 104. <br /> BUSINESS SITE ADDRESS to3.=Stockton, <br /> 440 W.Charter Wy 95206 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> 4— WORK AUTHORIZED UNDER PERMIT 483b. <br /> TYPE OF FR03117r(Check all that aooTv) <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Num6cr or Datc): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SR 0059048/1-14-10 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> RAM <br /> 483c <br /> DESCRIPTION OF WORK BEING CER'T'IFIED: <br /> 91 MLLD Certification: <br /> 1-14-10 9:00a Tested 91 MLLD with EHD Inspector Ray Von Flue.All Test Passed. <br /> III. CONTRACTOR INFORMATION <br /> 482,. <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> Gavin Williams <br /> 482. <br /> ' <br /> CONTRACTOR LICENSE M CC CERFCTION H <br /> UA <br /> 856771 6018864T . <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 cued <br /> by a registered professional engineer having education and eat 'ence with underground storage talo stem installations. 4� <br /> SI ATURE O TANK OWNER OR OWNER'S AGENT DATE <br /> NF <br /> 1/14/10 ( 209 ) 467-7573 <br /> 483 486. <br /> CERTIFTER'S NAME(prod) CERTIFIFR'S TITLE: <br /> Gavin Williams Tech <br /> 4ss' <br /> NAME OF CERT11FIER'S EM418 EMPLOYER(DBA) CER rWIER'S RELATIONSHIP TO TANK OWNER <br /> HMC-Henderson Maintenance Company ❑ L TANK OWNER ❑ 2 TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ® <br /> S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> Rev.(122007) <br /> UPCF UST-C-112 <br /> Q�� D <br />