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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project) <br /> L FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(S.u FACUTY MAW aDBA-e .,Bab.A:) 3' <br /> Costco Gasoline Loc. 658) <br /> BUSINESS SITE ADDRESS iO3. CITY 104.3250 W. Grant Line Rd. I Tracy, CA 95377 <br /> H.INSTALL.A'TION 1 MODIFICATION PROJECT DF'SCRLPTION <br /> TYPE OF PROJECT(Check all that aoely) 483.. WORK AUTHORIZED TINDER PERMIT °S3e. <br /> ® 1.TANK INSTALLATION OR REPLACEMENT (Nmber or Date): <br /> ® 2.PIPING INSTALLATION OR REPLACEMENT <br /> ® 3.SUMP INSTALLATION OR REPLACEMENT SR00661565 & SR0066164 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 43x <br /> Installation of 1,500 gallon CSI UST, Ameron 3" over 2" firberglass pipe and DW Additive tank sump. <br /> 87Main, 87 Syphon & 91 Single wall fill sumps were upgraded to Double Wall Sumps to meet <br /> AB2481. <br /> LQ. CONTRACTORINF'ORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION,MODIFICATION 48h <br /> Wayne Perry, Inc. <br /> CONTRACTOR LICENSE# ' ICC CERTIFICATION# 4Sa_ <br /> 300345 5252084 Exp. 7/05/13 <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 the requirements set 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 any manufacturer's written installation instructions. <br /> • All work listed in the manufacturer's installation checklist has been completed. <br /> • The installation has and approved by the local agency,or if required by the local agency,inspected and certified <br /> by areis r en ' r having education and ex erience with underground storage tank system installations. <br /> TU A OR R'S AGENT DATE 484. 1 PHONE 497. <br /> 5/2/2013 (714) 398-2180 <br /> CERT R'S N (print) °D CERTIFIER'S TITLE: 488' <br /> A y as Project Manager/Supervisor <br /> AME OF CERTIFIER'S EMPLOYER(DBA) 499 CERTIFIER'S RELATIONSHIP TO TANK OWNER 488. <br /> Wayne Perry, Inc. ❑ LTANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5-OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF USI'-C-112 Rev.(12/2007) <br />