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t- g 0 � 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 /> FACILITY ID # (Agency Use Only) t. <br /> I <br /> BUSINESS NAMES• a FACILMYY NAME w DBA Doing Buenas As) 3 <br /> BP/Arca #5450 <br /> BUSINESS SITE ADDRESS 109. CITY io4 <br /> 1617 W. Fremont St IStockton <br /> II. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT (Check all that spilt') 483& WORK AUTHORIZED CINDER PERMIT 483b <br /> ❑ 1 . TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2. PIPING INSTALLATION OR REPLACEMENT San Joaquin EHD 5R#0079636 <br /> [33. SUMP INSTALLATION OR REPLACEMENT q <br /> ❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5. OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 49k <br /> Remove existing straight droptubes and replace with flapper style droptubes and remove bail-floats from all USTs . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION 4S2e. <br /> Gettler-Ryan Inc <br /> CONTRACTOR LICENSE # 4e2b' ICC CERTIFICATION # 48ic <br /> 220793 8205730 <br /> XV. 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 /> o All work Iisted in the manufacturer's installation checklist has been completed. <br /> 6 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 gineer having education and ex erience with underground storage tanks stem installations. <br /> SIGN A F TNK O 48PHON4RE <br /> 482 <br /> 1 /21 /19 { 916 ) 851 - 1830 <br /> E FIER'S NAME (print) 495 CERTIFIER'S TITLE: 496 <br /> ichael Carruth Project Manager <br /> NAME OF CERTIFIER'S EMPLOYER (DBA) 482 CERTIFIER'S RELATIONSHIP TO TANK OWNER 499 <br /> r Gettler-Ryan Inc ❑ 1 . TANK OWNER [12, TANK OPERATOR <br /> ® 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br /> ❑ <br /> 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C - 1/2 Rev. (1212007) <br />