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UNIFIED PROGRAM CONSOMDATKD FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One Am per project) <br /> I. FACILM INFORMATION <br /> FACIU'I'Y t0 4 Cft rm,Uro Only) [ <br /> nUSINL•5$NAME(.rwv nr r�irc/Ary Nome er paA Lorng aware,x ASJ r <br /> Costco Gasoline Loc. #TBD <br /> NUSINESS SITE ADDRCS5 [m I CITY iM <br /> 2440 Daaicls Street Manteca <br /> H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(drer4glt 4rarmlyl 1R). W0RKAUrHOR14EUIINDERPERMrr .rn. <br /> ® L TANK INs'rALI.ATION OR REPLACPMCNT (Number or Dale); <br /> IR 2.PIPING INSTALLA'1"ION OR REPLACEMENT <br /> 3.SUMP INS'['ALIA`1[ON OR REPLACEMENT SR0052107 <br /> ® 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> [L5.Ul'k Elt <br /> OCSCRIYI'ION Of WURK aBING CER'CIFIED: ,rq <br /> The scope of work includes the installation of three(3) 30,000 gallon underground gasoline storage tatlks, <br /> served by a Phil-rite enhanced Stage I vapor recovery system,employing a double fill configuration in <br /> accordance with Dcccutive Order VR-101-1. Also permitted are 16 fueling points with 16 gasoline dispensing <br /> nozzles served by a Healy Enhanced Vapor Recovery(FVR)Phase I1 system, including a Veeder-Root in- <br /> Station Diagnostics (ISD)system,approved under F,xeeutive Order VR 202 B. <br /> M. CONTRACTOR INFORWATION <br /> NAME OF CONI KAC'I OR WI 10 PERFORMED INShALLA'I'ION I MUUIFICAI"ION .n7, <br /> TOL✓. .� Cv//-�T/t r C�--�T.?Ac"rMJ /.✓!o/r�o.��>c� <br /> CUNTRAC}'OR LICENSE q ICC CER'RFICA'1'nIN s a,zF <br /> 2-78//2 5 ,;:r75-6 S7-al <br /> 1V, CERTIFICATION <br /> I certify that the infor motion provided herein Is true,accurate,and that the foMwing conditions have been satisfied: <br /> • The installer has met the requirements out forth in 23 CCR§2715,subdivisions(g)mud(h). <br /> • The underground storage tank any primary piping, and any aeoondery containment was installed according to oppiieable <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 rc istcrod oro&ssional an 'neer having education and ex erIM00 with undecarmund store tanks stem installations. <br /> RE OF 1'AN! NE OR OWNER' AOEN"I' OATG +!+ PHONE 417 <br /> Q4004() AUs dT" 200 (y/6 )K 76 P3oo <br /> io <br /> 7�21R'SNAML'(pi;nF kJ res ULR'1'11 ILR'S TITLE, qru <br /> Lf�Ti`•�ri 2u.��[t r9s� /�L vi'�r,Gesir <br /> NAME OF CL•'R'111'ICR'S CMPLOYCR CUBA) '°[ CERTIFI!_R'S REIATIONSHIPTO TANK OWNER rn <br /> ❑_,>TANrOWNER 02.TANKOPERATOR <br /> /.^�iro/1Pv�?�vTc�p (II 3.CONTRACfOR ❑ 4.PROPUIt7NOWNEIZ <br /> ❑ S.OTIII•RAIrrIIORI41!PAOENT OF i'ANKOwNER <br /> UPCF UFT-C Rev.(IM0a71-Y2 rrww.ue14o ora <br />