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Nov 11 09 08.54a Reliable PetroleumA 209-845-8953 p.2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> 'UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILITY ID R(Agency Use Only) �. <br /> BliSINES$NAME(Sarre as!•'aeilityName or DBA—Doing Businexsds) s. <br /> Char+err 1� ��1 Cl�e�/rvh <br /> BUSINESS SITE ADDRESS im. CITY wt. <br /> E r6� W, cho,.r{-Cr Way 3j&k f-al� c.} 9s- z u�o <br /> R. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Clee¢k all that onok•1 4831, WORK AUTHORIZED UNDER PERMIT 4836 <br /> ❑ I.TANK INSTALLATION OR REPLACEMENT (Number or Daze): <br /> ❑ 2 PIPING INSTALLATION OR REPLACEMENr <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT � tir+Cl Z <br /> ❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> i.OTHER <br /> DESC/RI_PT1OF WORK BEING CERTIFIED: a33c. <br /> l�ha)iz (jwt- -AJ' (_.(KYi ,'( C JPi1 � BU(iez� Oy-) <br /> 4-4 q l phase, Coed �;v) . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MOD]FICATION 4M <br /> lxadalv.pz wile-kcz <br /> CONTRACTOR LICENSE q 48''" ICC CERTIFICATION# 48>_` <br /> 8S37L'(c 525 vers �- 11i <br /> IV. CERTIFICATION <br /> I certify that the information provided herein is true,accurate, and that the fallowing 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 professional engineer havingeducation and ex erience with underground storage tank system installations. <br /> Sli TURq OFTANK OWN OROIP,JER'SAGENT DATit Q �� 4e+ PHONE ��UN_�f33 (487. <br /> � <br /> CERTI 'S NAME(print) V 483' CERTIFI ' 'S 1T E: V 4=6. <br /> ri ay n�AO-Y+ Yb ( ) <br /> MAME 7// <br /> TIFIER'S EMPLOYER(DBA) 488' CERTIFIER'S RELATIONSHIP TO TANK OWNER 485. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPER.47OR <br /> L+1 3.CONTRACTOR [I4.PROPERTYOWNER <br /> l I I / rfY ❑ 5,OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF GST-C Rev.(12/2007)-112 www.uaidocsore <br />