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n <br />rWtFIED PROGRAM CONSOLIDATED FORM <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 />L <br />BUSINESS NAME (Same as Facility Name or DBA — Doing Business As) 3. <br />Unified Grocers <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />1990 N. Piccoli Rd <br />Stockton, Ca. 95202 <br />1 <br />II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that op 483, <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />SR -0056289 <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />0 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 4830. <br />Install new OPW ISC-2100 SPILL BUCKET <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 482a <br />A & J Environmental Services Inc <br />CONTRACTOR LICENSE # aszb. <br />ICC CERTIFICATION # 4820. <br />653381A-HAZ <br />5252300 -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 />• Thep, installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br />by iNegistered professionpj engineer having education and ex erience with underground storage tank system installations. <br />SIGNAT OF TANK OWNER OWNER'S AGENT <br />DATE 484. <br />PHONE 487. <br />2/18/2009 <br />(909) 597-9702 <br />CERTIFIER'S NAME (print) 485. <br />CERTIFIER'S TITLE: 486. <br />Asa Cosby <br />President <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488. <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br />A & J Environmental Services Inc. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />® 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />