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.a <br /> IED PROGRAM CONSOLIDATED FO <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION (0„ <br /> I.FACILITI ]DEN'IIFICA'IION <br /> FACILITY ID#(Agency Use Onl), <br /> BUSINESS NAME(S...FACu.FlY NA ur DBA-D..g u�sm.M) , <br /> BUSINESS SITE ADDRESS CITY 104 <br /> II.INSTALLATIONAIODIF'ICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) WORK AU'FI IORIZED UNDER PFRYIII' 48's <br /> L TANK INSTALLATION OR REPLACEMENT (Number or Date) <br /> 2.PIPING INSTALLATION OR REPLACEMENT <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 /> "c, Ill.CONTRACTOR INFORMATIO.,;,M yp. <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482" <br /> CONTRACTOR LICENSE# 4826 I ICC CERTIFICATION# 482` <br /> IV.CERTIFICATION <br /> I certify that the information provided herin is true,accurate,and that the following conditions hate been satisfied: <br /> • The installer has met the requirements set forth in23 CCR 2715,subdivisions(g)and(h). <br /> • The undergound storage tank,any primary piping,and any secondary containment was installed according to applicable voluntary consensus standards and <br /> 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 by a registered professional <br /> engineer having education and experience with underground storage tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 404 PHONE 487 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE 486 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489a <br /> 1.TANK OWNER "' 2.TANK OWNER <br /> 3.CONTRACTOR 4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C <br />