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Aft <br /> NIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project.) <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) Ti] <br /> BUSINESS NAME(Same ae FACILITY NAME or DBA—Doing Business As) 3. <br /> Gas Depot <br /> BUSINESS SITE ADDRESS I03. 1 CITY 104. <br /> 1330 E Yosemite Manteca, CA <br /> H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483aWORK 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 SR0057675 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> Rl 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Cold Start Monitor Certification. <br /> 10-29-09 9:30a Tested all Sensors and changed Setup of Output Relay to Shutdown on Liquid Waming per <br /> Environmental Health Inspector Munny that was on site during Certification. <br /> Tested Fail Safe, Sensor Out and Positive Shutdown.All Tests Passed. <br /> HL CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482s. <br /> Gavin Williams <br /> CONTRACTOR LICENSE# 482b" ICC CERTIFICATION# 482c' <br /> 856771 6018864-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 stor a tank s stem installations. <br /> SIGNA OF�r OWN'ER OR OWNER'S AGENT DATE 494- PHONE 487. <br /> 10/29/09 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. <br /> Gavin Williams Technician <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) Ogg CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> HMC-Henderson Maint Co ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ® <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />