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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form pc pmiect) <br /> L FACELITYDiFORMATION <br /> FACILITY ID#(Agency Use Onfy) 1 <br /> BUSINESS NAME(s.®..FACn1rVNAA RDBA-Do;"8 n,,,m,sa a) r� <br /> Costco Gasoline Loc. 658) <br /> BUSINESS SITE ADDRESS BOJ. CITY <br /> 3250 W. Grant Line Rd. I Tracy, CA 95377 <br /> II.INSTALLATION I MODIFICATION PROJECT DESCR MON <br /> TYPE OF PROJECT(Check all that my N) 48r°. WORK AUTHORIZ®UNDER PERMIT 481t. <br /> ® 1.TANK INSTALLATION OR REPLACEMENT (Number 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 /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 481, <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 /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION,MODIFICATION 48L. <br /> Wayne Perry, Inc. <br /> CONTRACTOR LICENSE# eem ICC CERTIFICATION# 4—u <br /> 300345 5252084 Exp. 7/05/13 <br /> ]Y.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 bS;*i5jpa4teq and approved by the local agency,or if required by the local agency, inspected and certified <br /> by areis e r Navin education and ex erience with underground storage tank astern.installations. <br /> TU A OR R'S AGENT DATE 484 PHONE eel. <br /> 5/2/2013 (714) 398-2180 <br /> CER7 RSNS (prim) CERTIFIER'S TITLE: 486. <br /> A y as Project Manager/Supervisor <br /> AME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 499. <br /> Wayne Perry, Inc. ❑ LTANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF T.OR OWNER <br /> UPCF UST-C-1/2 Rev.(12/200') <br />