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J <br /> U IED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION (One fora per rre)eep <br /> 1.FACILITY IDENTIFICATION <br /> FACILITY ID#(Agency Use Onh) <br /> BUSINESS NAME(same as FACB.rrY NAAHE or DBA-Doing Business Ao 3 <br /> BUSINESS SITE ADDRESS CITY 104 <br /> 11.INSTALLATIONIMODIFICATION PROJECT DESCRIPTION <br /> IYPEOFPRO.IEC I (Check all that apply) WORK AUTI IORIZED C A'DL'R PLRMf f 4s;e <br /> 1.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 493C <br /> III.CONFRACFOR INFORMATION <br /> NAME OF CONTRACTOR WI 10 PERFORMED INSTALLATIONIMODIFICATION 48's <br /> CONTRACTOR LICENSE# 4826 ICC CERTIFICATION# 4822` <br /> N.CERTIFICATION <br /> 1 certify that the information provided berin 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 undergound storage tank,any primary piping,and any secondary containment was installed according to applicable voluntary consensus standards mid <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 PHONE 487 <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE 486 <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 498 CERTIFIER'S RELATIONSHIP TO TANK OWNER 485a <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 />