COMPLIANCE INFO_2008-2009 - Laserfiche WebLink

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Ab M IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION/MODIFICATION (One form per project.) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 177 BUSINESS NAME(Same as FACn.rrY NAME or DBA-Doing Business As) 3. Quik Stop #148 BUSINESS SITE ADDRESS 103 CITY 104. 205 W. Lockeford Street Lodi H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT(Check all that apply) 413a. WORK AUTHORIZED UNDER PERMIT 483b. ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2.PIPING INSTALLATION OR REPLACEMENT ❑ 3.SUMP INSTALLATION OR REPLACEMENT ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT X 5.OTHER DESCRIPTION OF WORK BEING CERTIFIED: 483c The 89 secondary lines failed Tri-Annual Compliance testing on 9-2-09 Performed Helium Investigation to locate leak on 9-10-09. Obtain the required permits for this work from the local CUPA.Includes permit fee.Saw out,remove and dispose of the concrete adjacent to the UDC#1/2.. Excavate as required to expose the secondary line.All backfill spoils to be stockpiled on site for reuse. Make necessary repairs to secondary line 89. Backfill,using existing backfill material. Install new concrete tank slab to match existing, with#4 rebar as needed. Perform a post-construction SB989 test. Provide final test results to CUPA and Owner. III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. Walton Engineering, Inc. CONTRACTOR LICENSE# 4s2b. ICC CERTIFICATION# 482. 617238 5243762-U1 IV.CERTIFICATION I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: • The installer has met the requirements set forth in 23 CCR§2715,subdivisions(g)and(h). • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable voluntary consensus standards and any manufacturer's written installation instructions. • All work listed in the manufacturer's installation checklist has been completed. • The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified by a registered professional engineer having education and ex erience with underground storage tanks stem installations. SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. (916) 372-1888 CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. Contractor NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. Walton Engineering, Inc. ❑ I.TANK OWNER ❑ 2.TANK OPERATOR ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER X 5.OTHER AUTHORIZED AGENT OF TANK OWNER UPCF UST-C-1/2 Rev.(12/2007)