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u-lay 21 02 10:24a E1it- Iv Contractors Inc 209461Fq42 P.1 7 <br />14ul-l-D13Y <br />z <br />ri <br />- <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATIO14AY 2 1 2008 <br />(One form per project) <br />L FACILITY INFORMATION�}?P,itIT.I r- <br />FACILITY ID # (.(gene~ Use On1v) <br />- _ <br />BUSINESS NAME (Same as Facility Name or DBA — Doing Business As) 3. <br />r,<�e.i <br />BUSINESS SITE ADDRESS I 03. <br />CTTY W4. <br />1 1 <br />i <br />II. INSTALLATION / MODIFICATION PROJECT DESCRIPTION <br />TYPE OF PROJECT (Check all that annlvl 481a. <br />WORK AUTHORIZED UNDER PERMIT <br />❑ 1. TANK INSTALLATION OR REPLACEMENT <br />(Number or Date): <br />❑ 2. PIPING INSTALLATION OR REPLACEMENT <br />[1 3. SUMP INSTALLATION OR REPLACEMENT <br />�� •� I P� <br />❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br />[.a" 5. OTHER <br />DESCRIPTION OF WORK BEING CERTIFIED: 083c' <br />l �`✓!1...'.i-..'c.... .J,_ C.,. toEC>C]r_ '}LY v,:V L.�`t"c <br />Jr- la ✓,^^ n ,� U) 1 `4h <br />rl�'`' 1 <br />M. CONTRACTOR INFORMATION <br />4N2a � <br />NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION <br />CONTRACTOR LICENSE # 462b. <br />ICC CERTIFICATION # 487t. <br />IV. CERTIFICATION l <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 professienak4igitieer havinq'eftcatto nd ex rience with underground storage tank system installations. <br />SIGNATURE OF TANK OATi£R ORO R'$,k — <br />4TE 484• <br />PHONE 487. <br />l J C <br />CERTIFIER'S NAME (print) 485' <br />j(Lrc <br />486. <br />CERTIFIER'S TITLE: <br />NAME OF CERTIFIER'S EMPLOYER (DBA) 488' <br />CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br />\ ' i ; <br />CL t V CL�t i�t-i-��Ll y L.I�tL . <br />❑ I. TANK OWNER ❑ 2. TANK OPERATOR <br />❑ 3. CONTRACTOR ❑ 4. PROPERTY OWNER <br />2-'S OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C Rev. (12!2007) - V2 www.unidomorg <br />