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RS <br />T UNIFIED PROGRAM CONSOLIDATED FON <br />UNDERGROUND STORAGE TANK rt13 L 2 2Qlg <br />CERTIFICATION OF INSTALLATION / MODUtpl,?M <br />r6 4 -VA -1 pro e c t.) <br />I. FACILITY INFORMATION <br /># (Agency Use Only) <br />(Same as FACHM NAME or DBA — Doing Business As) <br />... �,...�..,.,.a �u <br />103. CITY <br />3ioc�--orn <br />II. INSTALLATION I MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that apply) 483i WORK AUTHORIZED UNDER PERMIT <br />48 <br />1. TANK INSTALLATION OR REPLACEMENT <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT (Number or Date): <br />❑ 3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />5. OTHER <br />DESCRIPTION OF WORK BEING CFRTIFTPn <br />UK Q(Q3 Ud.c S4 u5c (f LLL CV,,e--,d Ueqt lc LJ�L— <br />III. CONTRACTOR INFORMATION <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION <br />CONTRACTOR LICENSE # 4826. ICC CERTIFICATION # <br />62 <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 en ineer having education and experience with underground storage tank system installations. <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 494. PHONE 4g7, <br />-)A. — - r . eri, •/1 <br />CERTTIFFIIER'S NAME (print) <br />14 17 <br />NAME OF CERTIFIER'S EMPLOYER (DBA) <br />UPCF UST -C - 1R <br />. la a-acrj (��r) at3.1�a t, <br />CERTIFIER'S TITLE: 486. <br />... CERTIFIER'$ RELATIONSHIP TO TANK OWNER <br />❑ L TANK OWNER ❑ 2. TANK OPERATOR <br />P3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />Rev. (12/2007) <br />