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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION / MODIFICATION <br /> (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) d dI <br /> BUSINESS NAME(Same as FACILFFY NAME or DBA—Doing Business As) 3. <br /> Safeway#5816 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 19555 South Mountain House Parkway Mountain House <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 483a. WORK AUTHORIZED UNDER PERMIT 483b. <br /> ® 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ® 2.PIPING INSTALLATION OR REPLACEMENT SR083832 12/3/2021 <br /> ® 3.SUMP INSTALLATION OR REPLACEMENT <br /> ® 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> ❑ 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> Installation of new underground storage tank system consisting of: <br /> - 30,000 gallon Regular Unleaded Tank <br /> - 15,000 gallon Premium Unleaded Tank <br /> - 15,000 gallon Diesel Tank <br /> - 6 Tank Sumps <br /> - Dobule Wall Fuel, Vapor and Vent Piping <br /> - 8 Underground Dispenser Containments and Dispsensers <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482x. <br /> B&T Service Station Contractors <br /> CONTRACTOR LICENSE# 482b' ICC CERTIFICATION# 482c' <br /> 902034 5250415 <br /> IV.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 /> • 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 professional engineer having education and ex erience with underground storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. <br /> '4Saone. 9/26/2022 ( 925-580-8131 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486' <br /> Aldo Basurto Assistant Sales Manager Fuel & Convenience <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> Safeway Inc. ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> ❑ 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />