Laserfiche WebLink
Dec. 7. 2010 9 : 59AM Doolae Pump Cc, No. 9452 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 LD#(Agency Use Only) e_ <br /> BUSINESS NAME(Same ar Facility Name or O@A—Doing Business Aa) s. <br /> ARv4 1?0(4rO cp+m Loc< <br /> BUSINESS SITE ADDRESS CITY 104, <br /> (1`733 ;5, NW`s `19 �Ir4Ge ST-oc4<TbiJ , CA ' <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aaalvl 485" WORK AUTHORIZED UNDER PERMIT 40b• <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date)! <br /> ❑ 2.PIPING INS'rALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT sR(•jOlO f o 38 <br /> ❑ 6.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER 39ooN f,.aKTArNmtN fR4tfzS <br /> DESCRIPTION OF WORK BEING CERTIFIED: ACs" <br /> ►,) t >n.� ttsSP�crc�s3 dF Drfs>=( ee(Q..GQIsP- <br /> sc�tsgct iIC to U, 9.C.. POP- -Tt� F"f�it_&�C C. rtSrs . <br /> o?�PleC2FoeZmpD DIAC+avoSttc PCZocJmPv�2iS tv c9tc-p-rra, gelpeCTltl <br /> I�ht�'C'CLgTTor.! ��esTS <br /> 3�Fvtzt.ttst�+co a�co c�srw4�rGo WsE.w Vrsl�ZsrAaso �os�ICTs R� <br /> y ot'{pfNAY>t0 tNSPf•CR�N $Y d �At��t�l ���IJ1Y a(A P <br /> 5'rR-F�' , �2Co¢r.-t>✓O ANa rr�ss�p (�ytS>�+SrAr(c TtsYs . <br /> �� �nrTrEo -r&ST, Rtstacrs To 6t- C>. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION I MODIFICATION <br /> CONTRACTOR LICENSE# 4 ' I ICC CERTIFICATION# 4esa <br /> �3aoa - c6/- gyo <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 /> by a registered or0fesSional engineer having education and ex erience with underground store a tanks stem installations. <br /> SIGNATUR OF TANK OWNER qJk OWNER' GENT DATE ^a PHONE 487 <br /> CE IER'S NAME(print) 4D' CERTIFIER'S TITLE: 4 <br /> ATPD C . Am rcro fJ AG�T" <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 4 CERTIFIEWS RELATIONSHIP TO TANK OWNER 489. <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> Q&3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5,OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C Rev.(122007)-112 "W.unldocs.org <br />