Laserfiche WebLink
r-1 <br />U IFIED PROGRAM CONSOLIDATED FORK <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 />I• <br />BUSINESS NAME (Same as FACILITY NAME or DBA— Doing Business As) 3, <br />Teichert Mobile Equipment <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />120 Frank Circle <br />Stockton <br />II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that annly) 111a. <br />WORK AUTHORIZED UNDER PERMIT assn. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />X 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483e <br />Replace the 87 spill container which is located in a sump. Replace the Diesel #2 ELLD. <br />Retest with CUPA inspector present. <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a. <br />Walton Engineering, Inc. <br />CONTRACTOR LICENSE # 1821. <br />ICC CERTIFICATION # 482e. <br />617238 <br />5243762-U1 <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 storae tanks stem installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT <br />DATE 181. <br />PHONE 48T <br />- 2-1 _ 10 <br />(916) 373-1166 <br />CERTIFIER'S NAME (print) 185 <br />CERTIFIER'S TITLE: asb. <br />Dulcinea Covan <br />Contractor <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 188 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 189, <br />Walton Engineering, Inc. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />❑ 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />X 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C - 1/2 Rev. (12/2007) <br />