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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> (� CERTIFICATION OF INSTALLATION/MODIFICA'TION <br /> (One fonn per project.) <br /> 1.FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Onl)oI 0I V[C(f d <br /> BUSINESS NAME(Same as FACILITY NAME ar DBA—Doing Business As) 3. <br /> Arco AM/PM Manteca <br /> BUSINESS SITE ADDRESS 103• CITY 104. <br /> 2056 Crestwood Ave Manteca <br /> II.INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that anniv) 413a•L(NumberorDate): <br /> RIZED UNDER PERMIT 4s3b. <br /> ® 1.TANK INSTALLATION OR REPLACEMENT <br /> ® 2.PIPING INSTALLATION OR REPLACEMENT <br /> 3.SUMP INSTALLATION OR REPLACEMENT July 26,2019 <br /> ® 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Installation of two doublewall fiberglass underground storage tanks as follows; <br /> One 25K regular tank and one 22K split compartment tank(12K Deisel and 1 OK Premium) <br /> Installation of NOV doublewall fiberglass piping system <br /> Installation of doublewall fiberglass tank sumps <br /> Installation of 10 new Bravo doublewall fiberglass under dispenser containment sumps <br /> i <br /> O <br /> III.CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WkiO PERFORMED INSTALLATION/MODIFICATION 4822. <br /> ViTendt and Sons Construction Inc <br /> CONTRACTOR LICENSE# 412b. ICC CERTIFICATION# 482e. <br /> 723360 A,B, C10,HAZ Don Gilmer Reg. #326483195 <br /> IV.CERTIFICATION I <br /> i <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). i i <br /> • The underground storage tank,any primary piping,and any secondary contaimnent 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 checldist 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 /> yA registered professional engineer having education and experience with underground storage tank system installations. <br /> rC. FT K W R OR OWNER'S AGENT DATE 4S4• PHONE 487• <br /> sial/ao 201- M-9—xL 0 3 <br /> i , <br /> AME(print) CERTIFIER'S TITLE: 486• <br /> Kenneth E Wendt a$5 President j <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER 489• <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> Wendt Construction axe `X 3.CONTRACTOR ❑ 4.PROPERTY OWNER I i <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />