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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (Ono form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) 1. <br /> BUSINESS NAME(Sw =FACBSfIY�NAMEor DBA-Doing Bui=;M) 3. <br /> V <br /> BUSINESS SITEADDRESS tm. CITY la. <br /> 50O W . 'jA, W <br /> II. INSTALLATION ODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that awl vl 483- WORK AUTHORIZED UNDER PERMIT 48% <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT �1 <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DE COIP ION OF WORK BEING CERTIFIED: 4a3c <br /> fi-eplac-ed Fe-Pva &and -/-) 1-eecCt1t-Aoc) TI-S -350 . <br /> T--S4-4 ct-ok aec�m n cc Ltyv, AD-le {e c , <br /> rrskW aU Leal! SenSOeS . ALL Tezwk pa�seCl . <br /> A L C es< W�e Aj { CGI( Val a-n IIPPd Ut-�o� Crrr,s©Je . <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION aeaa <br /> Pe It !e e leur" t view 10aA-J <br /> CONTRACTOR LICENSE# °83h ICC CERTIFICATION# <br /> ,a5as� -- u T N 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 /> re 'stored arofession gineer having educa' n and ex 'ence with underground storage tank s stern installations. <br /> GNAT OFT OWNER R'S AG�T DATE °M PHONE 4Sr. <br /> v CSL dl� a 3 09 ( 204 Otl-933 <br /> C R'S NAME n[) °SS CERT R'S E: <br /> Jaen h �n <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER 489' <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> �� ❑ <br /> 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(1212007) <br />