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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROIIND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (011e fbrm per project) <br /> I- FACILRY INFORMATION <br /> FACILI'I'y LD 0(Agzwq Um Only) i <br /> UUSINE'SS NAME(M~.Prhm00fy Nnnie•r OUA Oo,ng&aftesAs) r <br /> Costco Gasoline Loc. #TBD <br /> RUSINESSSITEADDRESS IN CITY �a <br /> 2440 Danicls Street Manteca <br /> R. INSTALLATION/MODIFICATION PROJECT I)ESCRUMON <br /> 'rYPEOFPROIEC'r AX"ka/(raalwmR.l ,^I• WORK ALITHOR14W unum PERMIT 'rm. <br /> 0 I,TANK INS'rALI.ArrON OR REPLACEMUNT (Number or Dill); <br /> 0 2.PIPING INSTALLA"1'1nN ORREPLACEN1CNr <br /> 19 3.Ei1MPiNS'IAL1,ATIONDRREPLACEMENT SR0052107 <br /> 0 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> _Qs U1 fait <br /> UESCRIPIPON OP WORK aELNO chit FIF1EU: ,yq <br /> The scope of work includes the installation of three(3) 30,000 gallon underground gasoline storage taroks, <br /> served by a Phil-Tito enhanced Stage I vapor recovery system,employing a double fill configuration in <br /> in <br /> accordance with lixeeutive Order VR-101-I. Also permitted are 16 fueling points with 16 gasoline dispensing <br /> nozzles served by a Healy Enhanced Vapor Recovery(EVR)Phase II system,including a Veeder-Root In- <br /> Station Diagnostics (ISM)system, approved under Executive Order VR 202 B. <br /> [U. CONTRACTOR INFORMATION <br /> NAME Or CONI KAC'I OR WI 10 PCRPORMED INS I ALLA HON I MODIFICATION <br /> TOS � Cov-�r�r Go-�ri1Ac"rc✓LI �.✓!'o/tpa/1,�r�D <br /> CONT14ACIOR LICENSE 9 •xm ICC CER'RFICATION 0 oze <br /> IV, CERTIFICATION <br /> I certify that the informption provided herein is true,accurate,and that the following conditions have been satisfied: <br /> The installer has met the requirements out forth in 23 CCR 12715,subdivisions(g)and(11)• <br /> + The underground storage lank any primary piping, and any 2000ndary containment was installed according to applicable <br /> voluntary consensus siatidards and any manufacturer's written installation instructions. <br /> All work fisted 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 re istered DrOftfiDnai en 'rust flavin epucelinn and ex eriencc with undo uud Storage tanks stem installations. <br /> RE OF I' NE OR DWNER' AGENT OATG <N PHONE 47 <br /> : i 14G� d 2Qo p (y/6 )6.76 ''3.00 <br /> CERTtFER'SNAML(Nint) ", CL,1'1'tI;WR'S TITLE, 9.. <br /> L�r/Ai7 zu��t��sy <br /> NAMEOF COI II/'hGR's CMPLOYLK NEA) °6° CER'rIFWR'S RELATIONSHIP'1'0 TANK OWNER .n <br /> TOLD F C97f/NlY t0 Ir///1C7p�Jf rl LirANKOwmm El2.TANK OPERATOR <br /> /t CONTRAMOR ❑ 4.PROPI111 YOWNER <br /> ❑ S.OTIIERAU'L'IIOR14CLIAOEN'r OF1'ANKOWNErt <br /> UPCF U51'-C Rev.(17!10071-Ih www.u•Wau,4rg <br />