Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION t MODIFICATION <br />L <br />(One form per pr,,ict.) <br />1. FACIIJTY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />i <br />BUSrNEO NAME (spas FACT YNAME mPAA-Do., 1111As) <br />4, - r S,?yV(*r3. <br />r �Z> �� <br />4 - <br />4c� e M <br />BUSINESS *TE ADDRESS 103 <br />L4 <br />CITY 104, <br />f --o <br />I 1; �0 e 'L <br />t-& SnQ T -Ht f not- <br />C #1 1 FT <br />11. INSTALLATION 1 MODIFICATION PROJECT DESCRIPTION <br />Xpl_y) 4113. <br />TYPE OF PROJECT (Check _4LdqLa <br />WORK AUTHORIZED UNDER PERMIT 483b. <br />❑ 1. TANK INSTALLATION OR RLPLACENIENT <br />(Number or Date): <br />?. PIPING INSTALLATION OR REPLACEMENT <br />3. SUMP INSTALLATION OR REPLACEMENT <br />❑ 4. UNDER DISPLNSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED:49k <br />Vk.,O,d 4 1 /9Jpj 'I <br />LV <br />f76wurLs d,0,4 U' V/4,11 '111ee <br />111. CONTRACTOR INFORMATION <br />NAME OF CONTRALTO WHO PERFORMED INSTALLATION/ MODIFICATION 4 2a <br />14(n Tol-t- C0V)C>6-zV,6'-q <br />CONTRACTOR LICENSE # V f 1121 <br />4 <br />ICC CERTIFICATION # <br />t4 q I o 5-3 biv . . ..... <br />. <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 tank system installations. <br />SIGNATURE OF TAN R OR OWNBR'S AGENT <br />DATE4" <br />PHONE 1487. <br />1( 661 ) 63q Ofel 5-0 <br />CERTIFIER , AME (print) 48S <br />486, <br />CEA ER'S TI LE. <br />V1 5 �1- S t <br />T <br />Zct <br />488 <br />NAME OF CERTIFIER'S EMPLOYER (DBA) <br />484— <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER <br />1. TANK OWNER 0 2. TANK OPERATOR <br />3. CONTRACTOR [j 4. PROPERTY OWNER <br />❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C - 1/2 Rev, (1212007) <br />