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a . t <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) <br /> VALPICO INVESTEMENTS DBA ARCO TRACY <br /> BUSINESS SITE ADDRESS 103. CITY "' <br /> 550 W. VALPICO RD TRACY <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aooly) 483& WORK AUTHORIZED UNDER PERMIT 4ri3h <br /> I.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Town &Country Contractors, Inc. installed two UST tanks at the above site to store fuel. The first tank is a split 10k these / <br /> 12k super and the other tank is a 20k gallon unleaded fuel. All new plumbing tank lines and dispensers were installed <br /> as well. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> Town &Country Contractors, Inc. <br /> CONTRACTOR LICENSE# 482b. I ICC CERTIFICATION# 482` <br /> 238112 5275557 <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 been inspected and approved by the local agency,or if required by the local agency, inspected and certified <br /> by ajejz�—Professionangineer having education and ex erience with underground storage tank system installations. <br /> 4CERTIFIE�RAME <br /> OWN OWN R'S AGENT DATE 484. PHONE 487 <br /> 10/9/12 X916- )997-4527 <br /> (print) 485 CERTIFIER'S TITLE: 48r, <br /> Latham ubillaga Plumber <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489 <br /> Town & Country Contractors, Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> IKI 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />