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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDF.RGROUNDSTORAGF.TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project) <br /> 1. FACILITY INFORMATION <br /> FAC'ILrry ID#(Agenev Use un(y) <br /> t <br /> BUSINESS NAML(Same w Facilim NOW err URA-Daing/raciness As) <br /> Valero #369803 CRY <br /> w <br /> BUSINESS SITE ADDRESS <br /> 153 E. 1 l a' Street Trac <br /> II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br /> TYPE(Ile I'ROJ FCf(C'heck all that anab•1 <br /> '"'• WORK ALTTHORIZIii3 TINDER PERMIT <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT SR0058665 <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.INDER DISPENSER CONI AINMFNr INSTALLATION OR REPLACEMENT <br /> Uo''TII ER <br /> DESCRIPTION OF WORK BEING C ERTIFIED: <br /> Replaced probe cable, and conduit nipple <br /> III. CONTRACTOR INFORMATION <br /> NAME OIc CONTRACTOR WHO PIeRFORMED NSTALLA'rION I MODIFICATION <br /> Alpha Petroleum Services, Inc. <br /> iCiP]a. <br /> CONTRA(TOR LICENSE;N CCCUR II FICAI ION# <br /> 742466 5242371-UT <br /> IV. CERTIFICATION <br /> I certify that the information provided herein is true,accurate,and that the following conditions have been satisfied: <br /> • Ibe installer has met the requirements set firth 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 any manulacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • 'rbc installation has been inspected and approved by the local agency,or if required by the local agency, inspected and certified <br /> bv a re istered rofecsional enincer having education and ex eriencc with underground storage tank system installations. <br /> &/AVI N ER OR WNIR'S AG ENI' DA"IG ect PIIONF '"2/12/2010 (707) 678-8100 <br /> SNAM (prin) cER'rinEicsrm.F: X86arnelli Permit Tech <br /> u° C'ERI IFIER'S REI.A'TIONSIIIP TO TANK OWNER 499_ <br /> NAME OF('T:RTIFIER'S EMPLOYER(I7HA) <br /> Alpha Petroleum Services, Inc. ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CON"TRACTOR ❑ 4"PROPER iY OWNER <br /> ❑ 5.0'1 HER AUTHORIZED ACEN'I OF'1"ANK OWNLR <br /> UPCF1 SI-C Ree.(12/2007).112 www.unidaer.arg <br />