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0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project) <br /> I. FACILITY INFORMATION <br /> FACILrFY ID#(Agency Use Only) <br /> BUSINESSNAME(Same as FName or DBADo <br /> — ing Business As) 3. <br /> acility <br /> BUS IN /S_ITE ADDRES,S 103. CITY 104 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check al!chat as (1 483a WORK AUTHORIZED UNDER PERMIT 4836. <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: 483 <br /> �U x . ,�'�°(`Ptd �b�/c lrn T•es•T'e �°, Cr ��� d .7�� <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482. <br /> PJ f d LI <br /> CONTRACTOR LICENSE# J00 Q / 4826 ICC CERTIFICATION#AfAiwL 482c <br /> L <br /> 2 5 <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 are istered rofessional engine havin education and ex erience with underground storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484. PHONE 487. <br /> CERTIFIER'S NAME(print) 485. <br /> CERTIFHiR'S TITLE: 485. <br /> n l d L/ /'e <br /> NAME OF CERTIFIER'S EMPLOYER IDEA) 488. CERTIFIER'S RELATIONSHIP TO TANK OWNER 499. <br /> '/ ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(12/2007)-1/2 w .uuldoes.org <br />