Laserfiche WebLink
a 6 <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 />t <br />BUSINESS NAME (Same u Ficnrry NAME m DBA -Doing Bmo ,As) 3 <br />Costco Gasoline (Loc. 38 <br />BUSINESS SITE ADDRESS 103. <br />CITY to <br />1630 E. Hammer Lane <br />1 Stockton, CA 95210 <br />11. INSTALLATION/?MODIFIC'AT'ION PROJECT DESCRIPTION <br />TYPE OF PROJECT(Check all that anDlvl 483x. <br />WORK AU'T'HORIZED UNDER PERMIT 4330. <br />® 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />® 2. PIPING INSTALLATION OR REPLACEMENT <br />® 3. SUMP INSTALLATION OR REPLACEMENT <br />SR0066145 <br />❑ 4. TINDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />❑ 5. OTHER <br />DEsciziv ION OF WORK BEING CERTIFIED: 4g3c <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 />.!Z III. CO_NTRACTORLNFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED MTALLATION / MODIFICATION aev. <br />Wayne Perry, Inc. <br />CONTRACTOR LICENSE # 4321. <br />ICC CERTIFICATION # 482c. <br />300345 <br />I 5252084 Exp. 7/05/13 <br />IV. C'ER'TIFICATION „ <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 installatio been ' ted and approved by the local agency, or if required by the local agency, inspected and certified <br />re's Tonal weer havin education and ex erience with underground storea tank system installations. <br />S NAT RE WNER'S AGENT <br />DATE 484. <br />PHONE 487. <br />ate' <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 />NAAE OF CERTIFIER'S EMPLOYER (DBA) ASS <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 434 <br />Wayne Perry, Inc. <br />❑ 1. TANK OWNER ❑ 2. TANK OPERATOR <br />® 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5.OTHF,R AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C -1/2 Rev. (122007) <br />