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• 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION I MODIFICATION <br /> (One form per project) <br /> L FACILTTV INFORMATION <br /> FACILI I Y 10 a(A6r1l Uir Only) I <br /> DUSINESSNAMd(.Trm,. rhbcll)ry Nl ,el,naA 011196MMe1As) 1 <br /> Costco Gasoline Loc. #TBD <br /> 9USINESS SITE ADDREMS I°r CITY iM <br /> 2440 Daniels Street Manteca <br /> II. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br /> IYPEOF PROJECTI1.0ec4 a((dial umbl "I• WORK AMHORIZED UNDER PERMIT <br /> R L'I'ANKINS'I'ALLATION OR REPLACEMENT (N11+ber or Dele); <br /> ® 2.PIPING INSTALLA'T'ION OR REPLACEMENT <br /> 19 3.5 UMP R4SrAIAWI'[ON OR REPLACEM ENT SR0052107 <br /> 0 4.UNDER UISPENSER CON't'AINMEN"1INSTALLA TION OK REPLACEMEN r <br /> R s.014ELEt <br /> OCSCRIPI'IDN OP WORK aEINO CER'CiMIEu� ,9q <br /> The scope of work includes the installation of three(3) 30,000 gallon underground gasoline storage tanks, <br /> served by a Phil-Tite enhanced Stage I vapor recovery system,employing a double fill configuration in <br /> accordance with Executive Order VR-101-1. Also permitted are 16 fueling points with 16 gasoline dispensing <br /> nozzles served by a Healy Enhanced Vapor Recovery(EVR)Phase 11 system, including a Veeder-Root In- <br /> Station Diagnostics (ISD)system, approved under Executive Order VR 202 B. <br /> PE. CONTRACTOR INFORMATION <br /> NAME OF LON IKACI OR WI 10 PERFORMED INSTALLATION!MODIFICATION .c7, <br /> /0/,/,v de Cr7!/r✓T�Y �O�✓T/1�9G TG>?�/ /i✓lo ?,�O/J 7d/J <br /> CONTKAOTOR LICENSE q p °1m ICC CER'RFICA11ON 0 <br /> IV, CERTIFICATION <br /> I certify that the information provided herein Nerve.accurate,and that the follnwiagcondltions have been satisfied: <br /> The ingtaller has met the requirements set forth in 23 CCR 12715,subdivisions(g)and(h)• <br /> • The underground storage lank 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 /> 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 laterad praftsional engineer havine education and ex ieneo with unde uod store tank s stem installations. <br /> TLE OF I' NE OR OWNER' AORN I' DATE ^°• PHONE M <br /> �dtYil/� /QU6 dTa 201 P V/V )6.76 /300 <br /> CERTIPER'SNAME(p,int) •"• CL'K3'FIER'S TITLE. vr)G�ir Ors:Z/?7/V/0/7 /// <br /> NAMEOF CHWI 111CR'S EMPLOYLACDBA) ase CER'rIFIER'S RELATIONSHIP 10 TANK OWNER 419 <br /> ❑>3. <br /> ,TANKOWNER ❑ 2.'rANK OPERATOR <br /> /i✓l9/l�G/�IS'T © 3.CONTRACIOR ❑ 4.PROPER:NOWNER <br /> ❑ S.OTIII;R AU'l'IIORIZl'U AGENT OF TANK OWNER <br /> IIPCF UYI'•C Rev.(17/20071•112 w9rw.unyoenarg <br />