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0 0 <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) <br />3 <br />BUSINESS NAME (Sone u FACIIM NAME or DBA- Doing Busmsss As) 3. <br />Costco Gasoline Loc. 38 <br />BUSINESS SITE ADDRESS 103. <br />CITY IN. <br />1630 E. Hammer Lane <br />I Stockton, CA 95210 <br />IT. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that auDlvl 483.. <br />WORK AUT HGRIZED UNDER PERMIT 4836. <br />® 1. TANK INSTALLATION OR REPLACEMENT <br />(Number ar Date): <br />® 2. PIPING INSTALLATION OR REPLACEMENT <br />® 3. SUMP INSTALLATION OR REPLACEMENT <br />SR0066145 <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />❑ 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 483c <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 />RECEIVED <br />JUN 13 2013 <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />III. CONTRACTOR INFORNL1TION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 462. <br />Wayne Perry, Inc. <br />CONTRACTOR LICENSE # 4836' <br />ICC CERTIFICATION # 4azc <br />300345 <br />5252084 Exp. 7/05/13 <br />TV. 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 installati been ' cted and approved by the local agency, or if required by the local agency, inspected and certified <br />re 's tonal a meer havin education and ex erience with underground storage tank system installations. <br />S NATRE R WNER'S AGENT <br />DATE 4a<. <br />PHONE 48�. <br />�, <br />6/13/2013 <br />(714) 398-2180 <br />CER 1 ' AME (print) 485 <br />CERTIFIER'S TITLE: 486' <br />An amas <br />Project Manager/Supervisor <br />N E OF CERTIFIER'S EMPLOYER (DBA) 486 <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 4N. <br />gyne Perry, Inc. <br />❑ 1.TANK OWNER ❑ 2. TANK OPERATOR <br />® 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C • 112 Rev. (12/2007) <br />