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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGF, TANK <br />CERTIFTCATION OF INSTALLATION MOD CATION <br />(Onc form.per prqjcct) <br />FSCl. .... . .... . <br />FACILErY Use Oni <br />TIONIMODIFICAT11 <br />F <br />TYPE OF PROXCT (Ch,,k aaAqL�d, <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />1 PIPING INSTALLATION OR REPLACEMENT <br />ZI 3. SUMP INSTALLATION OR REPLACEWNT <br />:1 4. UNDFJO)ISPENSFIZ CONTAINTMENT INSTALLATION O(t jZFXLACENMW.r <br />71 5, oTHrm <br />rECT DIESCRIP-.ON., <br />.4 <br />WORK AUTHORIMI) UNDER PF.I(Ma <br />(Number arDatc); <br />I- (\ <br />10 <br />ED <br />0110U) 1760 <br />ARR 3 0 Z009 <br />SAN JOAQUiN COUNTY <br />ElTXRONMENTAL <br />HEALTH DEPARTMENT <br />-1= J r -M, I UK WJ1U 1'ZKf'VKM1iV INSTALLAoulkICAT ]ON 4K'& <br />TION/M <br />CONTRACTOR LjcENsE 4a <br />7-ceP,-nFicA-noN <br />I certify that the inforsnation provided herein is true, accurate, and that the following conditions have been satisfied: <br />• The fintaller has met the requirements set forth in 23 CCR ¢2715, .subdivisions (g) and (h). <br />• Tbc underground storage tank, arty primary poring• and any secondary containment was installed according to applicable <br />voluntary consensus standards and any manulucturer's written installation instructions. <br />• All work IiNud in the manufacturer's installation checklist has been completed. <br />• The installation has been inqpwtcd and approvod by the local agency, or if required by the local agcncy, inspected and certified <br />by a rqqstcred Profcssional rngineer having education and <br />SIGN4TURE-OF TANK OWNER Q&0LWMt1S AGENT experience with underground storage tank system installations <br />I DATE - t 484. 1 1-14ONP. <br />P07 <br />CERTIFIER'S NAWF, (7Tint) ClIRTIFIER, S TITLE: 4N. <br />NAME Or, R TIFTER'S EM PLOItTR (DEA) 498. <br />CERTIFIFA'S RI!LATIONSHIP To TANK OWNL�R <br />[:1 I.TANK OWNT.It- 171 -2. TANK -OPERATOR <br />.0 3. CONTRACTOR ❑ 4, PR())'E(C)-y OWNFK <br />0 s. OTHr.R AUTHOP,17.11D A(".FNi* OF i*ANK owm.,. <br />UPCF UST -C Pxv. (1=2*07).1/2 www.waldamarg <br />T.cj 2t,69T9*1302 OUI SJ0%0eJ2U00 AI a2T13 ese:ol: 60 De j4u <br />