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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION / MODIFICATION (One form per project.) I. FACILITY INFORMATION FACILITY tD # (Agency Use On1)J 1. BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3. Verizon Manteca Central Office BUSINESS SITE ADDRESS 103. FITY 104. 430 W. Center Street Manteca H. INSTALLATION / MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT (Check all that anoly) 4833- WORK AUTHORIZED UNDER PERMIT 4836. ❑ 1. TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2. PIPING INSTALLATION OR REPLACEMENT sRa61 Y 62 ❑ 3. SUMP INSTALLATION OR REPLACEMENT ❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT is 5.OT14HR DESCRIPTION OF WORK BEING CERTIFIED: 4833- • On December 30, 2009 the Veeder Root piping vault sensor model number 794380-320 was replaced like for like, tested and found to be functioning within the manufactures specifications. The sensor was retested on September 16, 2010. • On May 20, 2009 the Veeder Root overfill alarm boa model number 790091-001 was replaced like for like, tested, and found to be functioning within the manufacturers specifications. The sensor was retested on September 16, 2010. III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/ MODIFICATION 4823- CONTRACTOR LICENSE # 4821 ICC CERTIFICATION # 4920. 703190 5256842 -UT 1 IV. CERTIFICATION I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: • The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable voluntary consensus standards and any manufacturer's written installation instructions. • All Work listed in the manufacturer's installation checklist has been completed. • The installati een inspected and approved by the local agency, or if required by the local agency, inspected and certified b a re i red r3- ' al engineer having education and ex erience with underground storage tank system installations. SIGNATV TANK QWNER OR OWNER'S AGENT DATE 494. PHONE 499. - October 14, 2010 I (909) 594-9850 CERT AME (print) 485 CERTIFIER'S TITLE: 4ss- Michael Barber General Manager NAME OF CERTIFIER'S EMPLOYER (DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. SunWest Engineering Constructors, Inc. ❑ 1. TANK OWNER ❑ 2. TANK OPERATOR 2766 Pomona Blvd. ® 3. CONTRACTOR ❑ 4. PROPERTY OWNER Pomona CA 91768 ® 5. OTHER AUTHORIZED AGENT OF TANK OWNER UPCF UST -C -1/2 Rev. (12/2007)