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FLED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK �l—J 1Jl <br /> CERTIFICATION OF INSTALLATION / MODIFICATI 20l® <br /> (One form per project) ENVjftAjgA1-_- I" <br /> I. FACILITY INFORMATION /T ALT <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) <br /> Country Club 76 <br /> BUSINESS SITE ADDRESS 103, CITY 104- <br /> 2575 Country Club Blvd. Stockton <br /> II. INSTALLATION /MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that ayply) 483a 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 SR0059044 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> Z 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Replace 87 product line leak detector with new Vaporless LD2000 Mechanical Line Leak Detector <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 48'' <br /> Central Petroleum Maintenance <br /> CONTRACTOR LICENSE# 4821 ICC CERTIFICATION# 482c <br /> 491948 5311530-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 /> b ,a registered professional engineer having education and ex erience with underground storage tank system installations. <br /> SIGNAT RE F TANK OW ER OR OWNER'S AGENT DATE <br /> 484. PHONE 487. <br /> �. 1/7/2010 (925) 462-4060 <br /> CERTIFIER'S NAME(print) 485, CERTIFIER'S TITLE: 486, <br /> Kathleen Henshaw CFO <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 482 <br /> Central Petroleum Maintenance ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4. PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org <br />