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07/07/2010 16:25 209-465-4988 HMC / SST PAGE 01/01 <br /> PROGRAM <br /> JUL 072010 UNIFIED UNDER ROUNDONSOLIDATED STORAGETANKORM <br /> CERTIFICATION OF INSTALLATION/MODIFICATION(One form per project.) <br /> C(:IUN-r( <br /> HEAUP!D-ERARTMENT 1, FACILITY INFORMATION 1 <br /> FACILITY ID#(Agency Use Only) _ <br /> 3. <br /> BUSINESS NAME(samoas FACILYIY NAME or DSA—Doing 8winM As) <br /> Pacific Pride <br /> 1�. <br /> BUSINESS SITE ADDRESS 11i3•=Lo:dit, <br /> 351 N Beckman 95240 <br /> 11. INSTALLATION 1 MODIFICATION PROJECT DESCRIPTION <br /> as3a WORK AUTHORIZED UNDER PERMIT 483b. <br /> TYPE OF PROJECT(Check all that annly) (Number or Date): <br /> Q 1,TANK INSTALLATION OR REPLACEMENT <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3,SUMP INSTALLATION OR REPLACEMENT SR0060332 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ® 5.OTHER 4WC <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Replace L-16 annular space sensor. <br /> Veeder-Root 794380-208 <br /> III. CONTRACTOR INFORMATION <br /> 4RZa <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> Henderson Maintenance Company <br /> •3FI2G <br /> 4g2b. ICC CERTIFICATION# <br /> CONTRACTOR LICENSE# <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 /> b a r istered rofessional engineer havingeducation and ex erience with underground stora a tank system installations. ��� <br /> SIGNA ;F- �AN( WNER OR OWNER'S AGENT DATE ��• PHONE7/7/10 ( 209 ) 467-7573Stu.lasCERTIFIER'S TITLE: <br /> CERT/ NAME print) <br /> Gavin R Williams 41 Technician —4811. <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> Henderson Maintenance Company ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> Rev.(12/2007) <br /> UPCF UST-C-1/2 <br />