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2 <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) L <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3. <br /> Costco Wholesale- Fuel Center <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> 2680 Reynolds Ranch Parkway Lodi <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aDDly) 483a. WORK AUTHORIZED UNDER PERMIT 483b. <br /> M 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> x❑ 2.PIPING INSTALLATION OR REPLACEMENT SR0060386 <br /> X❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ® 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c. <br /> Installation of(3) 30,000 gallon "Containment Solutions" double wall fiberqlass Underground Storage Tanks. <br /> Installation of 8 new Gilbarco dispensers on new double wall fiberglass dispenser containment sumps. <br /> New Healy Phase II EVR system with CAS unit&Veeder-Root ISD monitoring. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482& <br /> Jason Hermosillo/Jones Covey Group,Inc. <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 482c. <br /> 804431 5252071-U1 <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 OWNER OR OWNER'S AGENT DATE 484. 1 PHONE 487. <br /> 5/25/2011 ( 888 ) 972-7581 <br /> 1 91011 <br /> CERTIFIER'S NAME(print) 485. CERTIFIER'S TITLE: 486. <br /> Ted Rodriguez Project Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> Jones Covey Group,Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 9595 Lucas Ranch Rd.#100 ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> Rancho Cucamonga,CA 91730 ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 www.unidocs.org <br />