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i 08/8/2008 14:20 FAX 510 614 8396 PARADISO ,MECHANICAL 16002 <br /> • <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One Pomt per prajee[.) <br /> L FACILITY INFORMATION <br /> FACILITY iD R(Agency Usc Only) 1. <br /> BUSINESS NAME(5•e•nFACILITYNAMExDBA—D i:ausiw•A.) <br /> Pacific Gas and Electric Company <br /> BUSINESS SITE ADDRESS 103. CITY 1w. <br /> 4040 M West Lane Stockton CA <br /> M INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all thaLaeelYl 'at• WORK AUTHORIZED UNDER PERMIT 'a3b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number cr Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> s.OTHER ft/ p n r 1L F2LY $ ST ,na. <br /> DESCRIPTION OF WORK BEING CERTIFIED' <br /> _Work Scone <br /> Install (2)-New Single Product Gasoline Dispensers with Conversion Frame. <br /> Install New Phase II EVR Healy System and Foundation Pad- <br /> Connect New Healy System to existing Vent Riser. <br /> Install (4)New Bollards and (4) cross members. <br /> W. CONTRACTOR INFORIVATION <br /> xA.ME OF CONTRACTOR wH0 PERFORMED INSTALLATION/MODIFICATION a <br /> Paradiso Mechanical Inc. <br /> CONTRACTOR LICENSE k ' ICC CERTIEICA'rToN a +ex <br /> 677909 5279139-VI <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 nlct 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 chccklist has been completed. ., <br /> • The installation has been inspected and approved by (he local agency,or if required by the local agency, inspected and certified <br /> by a registered professioftal ea ince'haven education and ex erience with under ound storage tanks stem installaLiOns. <br /> SIGNATURE OF TA45KGWNER OR OWNER'S AGENT <br /> DAT <br /> 3°+ PRONE 'e� <br /> d// g- H• og (5/0 )61H X5390 <br /> CERTIFIER'S NAME(print) +M CERTIFIER'S TITLE: +a6 <br /> L A i Z1, <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) +H CERTIFIER'S RELATIONSFIIP TO TANK OWNER 's"0 <br /> ❑ I.TANK OWNER ❑ '.TANK OPERATOR <br /> Paradiso Mechanical Inc- 3.CONTRACTOR ❑ a.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-12 - Rev.(1211007) <br />