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IF <br /> UNI PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATIONIMODIFICATION (p„e r,,,,,,P«pi-q� t) <br /> L FACILITY IDEN"II FICATION <br /> FACILITY ID#(Agency Use Only) , <br /> BUSINESS NAME(Sameas FACB.ITYNA or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDRESS CI"IY ioa <br /> It.INSTALLATIONAMODIFICATION PROJECT DESCRIPTION <br /> TYPF OF PROJLCI (Check all that apply) 483a WORK AUII-IORIZED UNDER PPRMH <br /> I.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 sir <br /> Ill.CONTRACTOR.INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482. <br /> CONTRACTOR LICENSE# 4826 ICC CERTIFICATION# 482, <br /> IN'.CERTIFICATION <br /> I certify that the information provided herin is true,accurate,and that the following conditions have 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 484 1 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 Ossa <br /> L TANK OWNER 2.TANK OWNER <br /> 3.CONTRACTOR4.PROPERTY OWNER <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C <br />