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D PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK CERTIFICATION OF INSTALLATION / MODIFICATION (One form per project) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) i BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3 SAN JC) IA-) C.Dv Ate' 6c ,4-;a9(-- BUSINESS SITE ADDRESS 103. CITY 104. ) UJ �� C U. INSTALLATION /MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT(Check all that apply) 483a. WORK AUTHORIZED UNDER PERMIT 483b. ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): ❑ 2.PIPING INSTALLATION OR REPLACEMENT ❑ 3.SUMP INSTALLATION OR REPLACEMENT /*)o J ?1[^� ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT l [1 5. DESCRIPTION OF WORK BEING CERTIFIED: 483c. WHILE CONDUCTING A SCHEDULED TRI-ANNUAL SB 989 SECONDARY CONTINMENT TESTING OF THE UNDERGROUND STORAGE TANK SYSTEM IT WAS NOTED THAT A SECONDARY CONTAINMENT PIPE FOR THE PRIMARY TURBINE SUPPLY LINE WAS CRACKED. THE CRACK EXTENDED FORM INSIDE THE SUMP TO APPROXIMATELY 4 INCHES OUTSIDE THE SUMP. FURTHER INVESTIGATION REVEALED THAT A SECONDARY CONTAINMENT PIPE FOR THE PRIMARY TURBINE RETURN LINE WAS ALSO CRACKED IN AN ALMOST IDENTICAL MANNER. REPAIRS WERE MADE AND ALL APPROPRIATE TESTING WAS CONDUCTED AND THE SYSTEM WAS RETURNED TO NORMAL OPERATIONS. III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a. CONTRACTOR LICENSE# ' ICC CERTIFICATION# 4szo. 7-7q S'D 6A P 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 installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified by aregistered professional en ' eer having education and a 'ence with ural and storage tanksystem installations. SIGNATYRE OF TANK OWNER OR OWNER'S AGENT DATE 494- PHONE 487. '4� &�� 495 RTIFIER'S NAME(print) " CERTIFIER'S TITLE: 48e. J 455:5�if yM Env ''cf M NAME OF CERTIFIER'S EMPLOYER(DBA) . CERTIFIER'S RELATIONSHIP TO TANK OWNER 499. j t �Qn ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR A.J�6:S [(3.CONTRACTOR ❑ 4.PROPERTY OWNER 1 ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER