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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF IN TAL LLAATION / MODIFICATION 0 4 2014 <br /> (One form per pro.ict) <br /> 1. FACILITY INFORMATION HEALTH <br /> E'AC'ILtF"i 11) d.rh rzcy I'se Onvl i <br /> F31,sr'tiC"457 Iti 1�f€ 6;ficrer� s 1^' c'rlatt' �>"z3srrm•trr!'JfA d�Jodn Nra-slraeais.i J <br /> Kaiser!Manteca <br /> BUSINESS SITE ADDRF Si C:'ITY 7 <br /> 1777 Yosemite Ave. 7Manteca <br /> II. INSTALLATION i MODIFICATION PROJECT D SC", I;IPTI N <br /> TYPE 011 PRCJ.lEiC'Whec*gff.Fj r,L���f2�k) �` NkOR AI,rl't!(' RIZIst)(!?�&)ER IIFs`RMI'I 4g-q, <br /> Q 1.1'ANK INSTALLATION OR REPLACEMENT NT (Acerber or Dato <br /> 1 11PIN6 INSTALLATION LATION OR REPT AC EMEN't <br /> 0 .1 St`NIP INS"I'ALLA`ION OR RE:PI AC EME,'N'I SIS-006772 <br /> [1 -t UNDER DISPENSER OR RF1Pl,r Cjr'xjj'N"T <br /> 5,C)TE1E>R _ <br /> 191 SC'RIPTR)N 01°WORK BEING CER I IFiFt): a <br /> Underground installation of one(1) 1.0°" Omega DoubleTrac fuel suply line, one(1) 1.5" Omega Double`1`rac <br /> return line, one(1)2" Arneron IXX vent line. Installation of associated Icon pipe:and conduit penetration <br /> fittings in STP sump. Re-fiberglass of one(1) STP Sump. <br /> Installation of one(1) 'Feeder Moat A-I'G probe($47390-107); one(1)"feeder Boat sump sensor(794380-1-08), <br /> and;one (1)UST interstitial sensor(794-390-1 for fluid-filled UST annular space leak detection. (Probe and <br /> sensors programmed into existing Veeder Root' S ASO consols i generator room) Sensors and probe <br /> installed with new cable. <br /> ,:�3 <br /> III. CONTRACTOR INFORMATION <br /> NAMFC?ECONTRACTOR WHOPIS.R€OR4bIMINS`IAI.LATIC5N tMCDIFIC'ATION 4824 <br /> CalPhase Construction, Inc. <br /> t.`ONrRAC°TOR I,IC°ME #1 4"' IC°C'C°ERTIFICATIC)N 0 <br /> 73773.51 8150904 <br /> IV. CERTIFICATION <br /> I certif} that the information provided herein is true,accurate.,and that the rollowing conditions have been satisfied: <br /> • The installer has met the:requirements sett forth in 23 CCR§271 S.subdivisions(g)and(h). <br /> a The tander round 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 complcted. <br /> « The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified <br /> registered rofessional en Bineer having education and ex erience with underground storage tarok system installations. <br /> SIONA F,o o 1:Rf7 t,)w a R-SA61',Nr DATF. 4X4 PHONE 49", <br /> ) <br /> C'E.R I IF-IFR S NAME(print) a� C'Ef#FTtF`It S 1.1.11 <br /> rMf Ca Cr1211F"ItF2 EP1,e)NTRrD13,11 CFRTFIlt:K'' Rl.n.�11t) SFIIP FS"NhC7 Nh,f2 x�,: <br /> k ;iCa '' � 'Wa+t 0 r FAltik_EJWNLR Q 2EANK 01'F'IRAI'OR <br /> 0 :3.C'()NrRA(.;j"tJR Q 4PROPERTY OWNER <br /> 01I IER Atj'I I4i3RVED AGE NTOF Tr11 K OW NE R <br /> t P(T US A'tbm(12/2007)-1/2 %,W".nnido s org <br />