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UE042 c , <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK , <br /> 1� <br /> CERTIFICATION OF INSTALLATION /MODIFICATION° <br /> (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) L <br /> BUSINESS NAME(same as FACILITY NAME or DBA—Doing Business As) 3. <br /> Pacific Bell Telephone Company dba AT&T California — UE042/SKTNCA01 <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> 345 N. San Joaquin St. Stockton <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a WORK AUTHORIZED UNDER PERMIT 4836. <br /> (Number or Date): <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT <br /> ® 2.PIPING INSTALLATION OR REPLACEMENT SR0065204(Env Health) <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT 12-1406(Bldg Dept) <br /> ❑ 4 UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483` <br /> Replace the single-walled fuel piping from the basement pump room to the rooftop generators with new double-walled steel fuel piping. Relocate US"r vent <br /> line. Install aboveground transition box and TLS sensor for fuel piping. Install floor sensors and generator belly tank high level sensors on each roof-top <br /> generator. Install secondary containment curb and epoxy floor in roof-top generator#1. Install secondary piping trap and TLS sensor on supply line to <br /> generator#1. Install generator run circuit to TLS. Upgrade the TLS overfill alarm by adding an acknowledgement switch. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> Gettler Ryan Inc._77 <br /> CONTRACTOR LICENSE# 4826 ICC CERTIFICATION# 482c <br /> 220793 Installer 5250443 Anthony Grijalva <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 a registered professional engineer having education and ex erience with underground storage tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484 PHONE 487 <br /> ,�- 9/20/13 (214) 464-2847 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486 <br /> Victor Guerrero Technician <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIEWS RELATIONSHIP TO TANK OWNER 489 <br /> Tait Environmental Services, Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> t1PCF UST-C-1/2 Rev.(12/2007) <br />