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s <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[D N(Agency Use Only) I. <br /> I T7T1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> Arco West Coast Products <br /> BUSINESS SITE ADDRESS 103 J CITY 104 <br /> 85 East Louise Avenue Lathro <br /> Il. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that @poly) 483` WORK AUTHORIZED UNDER PERMIT 483b <br /> ® 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ® 2.PIPING INSTALLATION OR REPLACEMENT Permit# SR0061245 <br /> ® 3.SUMP INSTALLATION OR REPLACEMENT <br /> ® 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER Dated: 11-12-10 <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Complete installation of UST Fuel System including installation of two (2) Containment Solutions <br /> Double-wall Fuel Tanks, Double-wall Fiberglass tank and Dispenser Sumps. Installation of Smith <br /> Double-wall Fiberglass Red Tread 11 fuel piping. Including ELD Testing. System includes one (1) <br /> 20,000 and one (1) 22,000 Split Tank with four (4) MPD Dispensers. System Monitored by Veeder <br /> Root System. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> Gettler-R an Inc. <br /> CONTRACTOR LICENSE N 4826 ICC CERTIFICATION N 482c <br /> 220793 <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 stal @tion has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br /> b a re i ered professional engineer having education and ex erience with underground storage tanks stem installations. <br /> SIGN A UR F TAN 0 E ORO ER'S AGENT DATE 484 PHONE 487 <br /> 3-11-11 <br /> (9 16) 851-1830Ext:117 <br /> CERTIFIER E(print) 485 CERTIFIER'S TITLE: 486 <br /> Craig Bell Project Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489 <br /> Gettler-Ryan 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-1R Rev.(12/2007) <br />