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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION(One to=per Project) <br /> I. FACIL17V INFORMATION <br /> FACILITY ID A(Agmry Uae Only) — — <br /> ,. <br /> BUSINESS NAME(s••e.�PncorlYNasmo,PeA-n,mae�A+) <br /> Yas t Q Czv pia l U RC CITY a. <br /> BUSINESS SITE ADDRESS '[ VO <br /> 116 t +fA- tK <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIP'T'ION 1ue <br /> M- WORK AUTHORIZED PERMIT <br /> TYPEOF PROJECT(Checke,l tial olvl (Number or Date): <br /> ❑ L TANK INSTALLATION OR REPLACEMENT <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDEA DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT JcTJ V— Coto ' �q <br /> enc <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> Vfp� U0.Ra✓l�sS LD -a666 cv1. <br /> M. CONTRACTOR INFORMATION Bzi <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> _ Sc, )%tek Tfr&Loci S -s-6n s. CLIC °em <br /> CONTRACTOR LICENSEq ICC CI7tTIFlCATIONM <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 arestered ofessional en eer having education and ex DAn�ce with under ound Stora a tank s stem installations, ar <br /> <ee. PHONE <br /> SIGNATURE OF TANK OWgNE1R Oft OWNER'S AGENT ' 1 '`Q U <br /> Ct wt;Lv U - Nt� a-t (. .n. <br /> °B1 CERTIFIER'S TITLE: <br /> CERTIFIER'S NAME(Ont) - <br /> � 1/3LZCit�l �• 1,l)E(TNatA� C l CLLLC-R e9 <br /> en CER77FI 'S RELATIONSHIP TO TANK OWNER <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> StV'UcCQ � � S LLL <br /> , <br /> ; <br /> I tLC-. ❑ S.OTHERAVFHORIZEDAGENTOFTANKOWNEA <br /> Rev.(12/2007) <br /> UPCF UST-C-112 <br />