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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UN DERG14OUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/.MODIFICATION <br /> (One form per project) <br /> i. FACILITY INFORMATION <br /> TITITFACR.rrY ID a(gSmcr U"Only) <br /> iIUSINESS NAME(.Yav nr FPelbryNome orOW Lomg BaslneaAsJ ' <br /> Costco Gasoline Loc. NTBD <br /> NUSINESS SITE ADDRESS Ico CITY <br /> 2440 Danicls Street Manteca <br /> U. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> '1'Y I'E OF PROJECT/Chrrk ay'&l IL nr.bl °°1i wmK AurHDRI'LEtt UNDER PERMIT ia <br /> IM L TANK INS'rAU.ATrON OR REPLACEMENT (N,i obw or Daw): <br /> ® 2.PIPING INSTALLATION OR REPLACEMENT <br /> I� 3.SUMP MS'i'AI.4ATION OR REPLACEMENT SR0052107 <br /> ® 4.UNUER DISPENSER CONTAINMENT INSTALLA'ITON OR REPLACEMENT <br /> Q <br /> S.OTItER <br /> OCSCRIP PION OF WORK HuENG CER'1'lF'IEUr <br /> The scope of work includes the installation of three(3) 30,000 gallon underground gasoline storage tanks, <br /> served by a Phil-Tito 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 II system, including a Veeder-Root In- <br /> Station Diagnostics (ISD)system,approved under Executive Order VR 202 B. <br /> III. CONTRACTOR INFORMATION <br /> NAMI'OF CON'I'RACIOR W I I D FURVOKMED INSTALLATION I MODIFIUKI ION '. <br /> T0L✓-,' 0 E0/%.IT//r /.✓!o/1Go/h�>cO <br /> LONLKACTOR LICENSE 4 ICC U11:11FICATION 9 a^:6 <br /> 238i�z <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 I'hc requirements sat 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 my 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 catered Prollessolonall on 'neer having education and ex erienco with undo and storage tanks stem installations. <br /> KE OF I'AN! NE OR OWNER' AOHN'r DATE ae° PHONE 411:dhi1/� 7414 19t✓air d"' 200 (P/6 )d76 1300 <br /> OSRTrPF.R'SNAML-'(mint) 11, CLW11FIER'S TITLE, <br /> L�ITi'/A/7 7Uf�[1�S'iy �L <br /> NAMEDFCURlllgCR'513MPLOYLRNEA) °6° CER'rmEws RELATIONSHIP TO TANK OWNER °p <br /> ❑ yTANKOWNER ❑ 2.TANK OPERATOR <br /> 3.COUrRACI'Olt 0 4.PROPEwry OWNER <br /> ❑ S.OTIIERAUTijoitr 'UAOENTOFI'ANKOWNER <br /> UFCF UFI'•C Rcr.(I2rIDarl.Ik nen.0 MI,Imao% <br />