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a <br /> UNIFIED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) I <br /> BUSINESS NAME(same as FACILITY NAME or DBA—Doing Business As) 3. <br /> CHEVRON #208117 <br /> BUSINESS SITE ADDRESS 101 CITY 104 <br /> 755 S. TRACY BLVD TRACY, CA 95376 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that auvly) 483a. WORK AUTHORIZED UNDER PERMIT 483b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ® 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: as3` <br /> SB989 Repairs (SJC Permit SR0066925) - All repairs made from inside the UDC, not concrete <br /> broken - remove dispensers 3/4-7/8-9/10-11/12, remove all penetration fittings in each UDC, install <br /> new Bravo fiberglass F-series split retrofit penetration fittings. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. <br /> WAYNE PERRY INC <br /> CONTRACTOR LICENSE# 482b. ICC CERTIFICATION# 482e. <br /> 300345 5115738 <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 /> RE OF TANK NER O R'S AGENT DATE 484. 1 PHONE 487. <br /> 6/5/2013 (916) 646-9680 <br /> IER'S N 485 CERTIFIER'S TITLE: 486. <br /> Brandon Smith Project Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> Wayne Perry Inc ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ® 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />