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AM <br />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 />1 <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3. <br />Quik Stop #120 <br />BUSINESS SITE ADDRESS 103. <br />CITY 104, <br />9321 Thornton Road <br />Stockton <br />H. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that anDlvl 411a. <br />WORK AUTHORIZED UNDER PERMIT 4836. <br />El 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: 483c <br />Installation of a complete new CPU Board and retest MS. <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a. <br />Walton Engineering, Inc. <br />CONTRACTOR LICENSE # 481. <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 stora a tank s stem installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT <br />DATE 484. <br />PHONE 487. <br />(916) 372-1888 <br />CERTIFIER'S NAME (print) 485 <br />CERTIFIER'S TITLE: 486_ <br />Contractor <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <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 />