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Ric. 7. 2010 10: HAM Donle� PUmp Co. No, 94-52 P. 3 <br /> UPCF UST Certification of Installation/Modification Fit Instructions <br /> (Formerly SWRCB Form C and UPCF Form hwfwre-c) <br /> This Certification form must be submitted upon the completion of installation or upgrading of tanks and/or piping associated with a <br /> UST system. Installation or upgrading of multiple tank systems may be addressed on one form. The UST owner or an authorized <br /> representative of the owner must complete this form.(Note: Numbering of these instructions follows the UPCF data element numbers <br /> on the Certification form.) <br /> 1. FACILITY ID NUMBER—This space is for agency use only. <br /> 3, BUSINESS NAME—Enter the complete Facility Name, <br /> 103, BUSINESS SITE ADDRESS —Enter the street address of the facility, including building number, if applicable. This address <br /> must be the physical location of the facility. Post office box numbers are not acceptable. <br /> 104. CITY—Enter the city or unincorporated area in which the facility is located. <br /> 482x. NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/ :MODIFICATION—Enter the name of the contractor <br /> who performed the work as registered with the Contractors State License Board(CSLB). <br /> 482b, CONTRACTOR LICENSE # —For the contractor named above, enter the license number assigned by the Contractors State <br /> License Board(license information is available online at www.cslb.ca.aov). <br /> 482c. ICC CERTIFICATION # —Enter the International Code Council (TCC) "UST Installation/Retrofitting" certification number <br /> possessed by the contractor. <br /> 483x. TYPE OF PROJECT—Check the appropriate box(es)to indicate the type of work performed. Address each system component <br /> individually(i.e.,for installation of a complete motor vehicle fueling UST system,check boxes 1 through 4). <br /> 483b. WORK AUTHORIZED UNDER PERMIT(Number or Date)—Enter the number of the permit issued by the local agency,or if <br /> no permit number,the date the permit or project approval was issued for the work being certified. <br /> 483e..DESCRIPTION OF WORK BEING CERTIFIED—In the space provided, briefly describe the work performed. Include the <br /> number and type of UST systems installed or upgraded and the scope of work (e.g„ "Installation of piping sumps and under <br /> dispenser containment, and replacement of product and vapor recovery piping associated with one 12,000 gallon regular <br /> unleaded and one 8,000 gallon premium unleaded motor vehicle fuel tank"). <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT—The tank owner or an authorized agent of the owner shall sign in <br /> the space provided. This signature certifies that the signer believes that all the information submitted Is true and accurate. <br /> 484. DATE CERTIFIED—Enter the date the form was signed. <br /> 485, CERTIFIER'S NAME—Enter the full printed name of the person signing the form, <br /> 486. CERTIFIER'S TITLE—Enter the title of the person signing the form. <br /> 487. PHONE—Enter the phone number of the person signing the certification. Include the area code and any extension number. <br /> 488. NAME OF CERTIFIER'S EMPLOYER—Enter the name(DBA)of the employer of the person signing the form. If the tank <br /> owner is an individual,and the owner signs the Certification,note"N/A"(Not Applicable)in this space. <br /> 489. CERTIFIER'S RELATIONSHIP TO TANK OWNER — Check the appropriate box to indicate the nature of the relationship <br /> between the person signing the form and the tank owner, <br /> UPCF UST-C Rev.(12dae7)-1@ www.uniJoca,org <br />