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UNDERGROUNDSTORAGETANK D PROGRAMCONSOLIDATED FORM RECO <br /> D 0 C T 10 2 012 <br /> CERTIFICATION OF INSTALLATIO /N MODIFICATION <br /> (One form Per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID k(Agenry Uu Only) <br /> BUSINESS NAME(Sa FACaliY Nnx�•oawg <br /> t Pc9.J J <br /> BUSINESS SITE ADDRESS <br /> rm. CITY <br /> 1340 C'.p(,� '° <br /> n INSTAL ON/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that cooly) <br /> I.TANK INSTALLATION OR REPLACEMENT WORK AUTHORIZED UNDER PERMIT 493n <br /> 2.PIPING INSTALLATION OR REPLACEMENT (Nrmrber or Date): <br /> 3.SUMP INSTALLATION OR REPLACEMENT <br /> 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5 OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> 4M <br /> �/U�%/�LL�JJBrJ � IU2ttJ �/j�Cf' �/71SN <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATTON/MODIFICATION <br /> CONTRACTOR LICENSE N °-- I ICC CERTIFICATION k <br /> o` <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 /> b a registered profession en ' eer havin education and ex rience with underground stora a tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 4%4. PHONE ` 4a7. <br /> CERTIFIER'SSNNAAME�(priinnt) , �f 465 CERTIFIE TITLE: <br /> NAME OF CERTTFIER'S EMPLOYER(DBA) 486 CERTIFIER'S R£LATTONSHIP TO TANK OWNER 489_ <br /> n n ` ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> /,IV, ElCONTRACTOR 4.PROPERTY OWNER <br /> 5-OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF US -C-12 <br /> Rev.(122007) <br />