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FIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) I V 3. <br /> Country Club 76 <br /> BUSINESS SITE ADDRESS 103. CITY 1T/ t!N104, <br /> 2575 Country Club Blvd. Stockton, CA 95204 CES <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 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 SR0064381 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ® 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br /> Replaced 87 fill sump sensor. Replaced S3 91 float sensor. Replaced S-5 diesel float sensor. Tested operation <br /> with inspector. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> Central Petroleum Maintenance <br /> CONTRACTOR LICENSE# 4826. ICC CERTIFICATION# 482c. <br /> 491948 15250561 <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 experience with underground storage tank system installations. <br /> SIGN URE OF TANK OWNVR OR OWNER'S AGENT DATE 484, PHONE 487. <br /> 2/29/2012 (925) 462-4060 <br /> CERTIFIER'S NAME(print) ass. CERTIFIER'S TITLE: 486. <br /> Kathleen Henshaw CFO <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489, <br /> Central Petroleum ❑ 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.unidoes.org <br />