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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) r. <br /> BUSINESS NAME(Same u FACMUY NAME mDBA—Doing Ro mAa) 3. <br /> �l tv\. v <br /> BUSINESS SITE ADDRESs 103, CITYAL HEgL'�°°. <br /> PERMff/SERVICES <br /> � � r} � <br /> IL IN ALLATION/moDiFicAnoNpFlojEcr DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 4831 WORK AUTHORIZED UNDER PERMIT 453b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP.UNDER DISPENSER INSTALLATION REPLACEMENT <br /> T <br /> INSTALLATION OR REPLACEMENT T <br /> .�`} <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 483c <br /> p 433e <br /> .r.�cH ��5� {� 4 c. � : 'ct� ct �LVe /l. t� �? <br /> Q•.�l ES�EfJ/ S�Luv l�v� -Cfs lZA- r um ct C�� <br /> U �teS� Pub C � 6041 /u- r ,CJ wt/ 6 * /"r/ �E Ayes C' <br /> III. CONTRACTOR INFORMATION <br /> N OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 4M <br /> (S /i✓I �� v✓l <br /> CONTRACTOR LICENSE# 4szb. ICC CERTIFICATION# `' <br /> -UT <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 r istered professional engineer having education and ex ience with underground storage tanks stem installations. <br /> -SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 4M PHONE 407. <br /> x ► l- - t ( ) <br /> CRTIFIER'S NAME(print) ass C TIFIF.R'S TIME- ass' <br /> �. L k <br /> NAME OF CERTIFIER-S EMPLOYER(I)BA) M C R'S RELATIONSHIP TO TANK OWNER "9. <br /> ❑ 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 />