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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION(one form per Project) <br /> I. FACILITY INFORMATION <br /> t. <br /> FACILITY ID 4(Agency Use Only) <br /> 1. <br /> BUSINESS NAME(s .FACaMNAa1Eo,DeA-Door9Bminns As) <br /> X0 51 �(Lw� Cc 1 O—. �j odu <br /> BUSINESS SITE ADDRESS 103. CITY 101 <br /> AL -YA 'R A . Lo-'((A.0 <br /> I1. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> an. WORK AUTHORIZED UNDER PERMIT 4136. <br /> TYPE OF PROJECT(Check all that ao0lvl <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT q 3 <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT SK C0 <br /> S.OTHER 4130 <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> res(,kLc�wte(�� 6t ZbF SaUSo✓e ok A'Oe-( )'ta(r+(& (( S'ul.yP <br /> M. CONTRACTOR INFORMATION <br /> NAME OF ,GNTRAcTOR.pWHO PERFORMED INSTALLATION/MODIFICATION °era <br /> U l�sC. S s lt-�'COl�1 S UkS ...(•lA`C. Ono <br /> ICC CERTIFICATION 4 <br /> CONTRACTOR LICENSEq 6 �O f r 6 D v I <br /> is 5 l 4 O `-k A <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 /> are 'stered professional engineer hGNeducerienre with underground storage <br /> tanks stem installations. <br /> PHONE <br /> S[GNROFTANKOWNROROWNASADATE 4a <br /> ,� to owu ( a8 ) X13 - (Doig <br /> 4es <br /> Ors CERTIFIER'S TITLE: <br /> CERTTFIER'S NAME(prim) �7_ r <br /> "Witf � '4�1�knk/ lD (CQ <br /> aaF. <br /> n <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) CERTIFIER'S RELATIONSHIP TO TANK OWNER <br /> ❑ L TANK OWNER ❑ 2.TANK OPERATOR <br /> .p.,,�" �3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> SeVJ LGe S�U+C0A :ittj, l Sic ❑ S.OTHERAUTHORIZED AGENT OF TANK OWNER <br /> R".(1212007) <br /> UPCF UST-C-12 <br />