Laserfiche WebLink
0 5 2019 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project.) <br /> L FACILITY INFORMATION <br /> FACIIM ID#(Agency Use anry) <br /> I <br /> BUSINESS NAME(Same asFACtt7rYNAME-DRA-IJaiez8vin Aa) <br /> BP/Arco#5450 <br /> BUSINESS SITE ADDRESS tRt <br /> CITY iw <br /> 1617 W. Fremont St Stockton <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROTECT(Check all that anolvl 4sa°. WORK AUTHORIZED UNDER PERMIT 4ue <br /> ❑ t.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT San <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT Joaquin EHD SR#0079636 <br /> © 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTkIER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 46 <br /> Remove existing straight droptubes and replace with flapper style droptubes and remove ball-floats from all USTs, <br /> I <br /> t <br /> 111. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION 492, <br /> Gettler-Ryan Inc <br /> CONTRACTOR LICENSE ICC CERTIFICATION 482C ' <br /> 220793 8205730 <br /> IV.CERTIFICATION <br /> 1 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 installation has been inspected and approved by the local agency,or if required by the local agency,inspected and certified <br /> by a registered profession ineer having education and experience with underground storage tanks stem installations, <br /> S1GNA F TANK O R O ' AGENT DATE 4a4 PHONE 4tn <br /> 1/21/19 ( 916 ) 851-1630 <br /> E FIER'S NAME(print) "s CERTIFIER'S TITLE: 4a6 p <br /> ichael Carmith Project Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 4HE CERTIFIER'S RELATIONSHIP TO TANK OWNERas <br /> Gettler-Ryan Inc ❑ l TANK OWNER [12.TANK OPERATOR <br /> i I$ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> L05,OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF OST-C-112 Rev.(124007) <br />