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., <br /> 07f23f2010 10:10 209-465-4988 HMC f SST PAGEQ Lu IU <br /> 01f�1� <br /> Jill <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATRNIG <br /> �(�rfe: iectJ <br /> 1. FACILITY INFORMATION <br /> FACILITY ID#(,Igwxy Use Only) <br /> a. <br /> BUSINESS NAME($ano as r•ACu.,iY NAME or DBA-Doing Bosi>im As) <br /> Waterloo Food&Fuel <br /> BUSINESS SITE ADDRESS t0S' CITY 104' <br /> 3032 E Waterloo Rd Stockton, CA 95205 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that as W 4831 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 SR0060405 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ® 5.OTHER <br /> 483c <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Replaced ATG, ROM module, STP relays and 87 annular sensor. <br /> Certified operability. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION 482° <br /> Henderson Maintenence Company <br /> CONTRACTOR LICENSE# 482b ICC CERTIFICATION# 48ZQ <br /> 856771 8016288-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 story-e an stem installations. <br /> SIGN TURF OF 1,ANK OWNER OR OWNER'S AGENT DATE 484• I PHONE 487• <br /> 7/21110 ( 209 ) 467-7573 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 4W <br /> Gavin Williams Contractor <br /> NAME OF CERTIFIER'S EMPLOYER(DSA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> Henderson Maintenance Company ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />