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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per prajectJ <br /> 1. FACILITY INFORMATION <br /> FACILITY N K(Agency Ute Only) t. <br /> BUSINESS NAME(s•,..FAC HAeo:w DBA-Dem,Buue m) r <br /> c Qroto <br /> BUSINESS SITE ADDRESS rm. CITY <br /> ta. <br /> 3 f 7 <br /> Ty-G-e lu& Tlro�c <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that soolvl °eta WORK AUTHORIZED UNDER PERMIT Ank <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT (*�� <br /> ❑ 54 UNDER OTHER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT v� 60/ 6 G zq (?Aa Ia <br /> DESCRIPTION OF WORK BEING CERTIFIED: P 1 <br /> 41 C(ecE✓bKtL <br /> `�.'° <br /> SEP 2 4 2010 <br /> �JOP,OU;., <br /> ENtnr?Q;J�t ;COUP. <br /> I'�tLllf OE�,�,gTMEt4Y <br /> M. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 44v <br /> TitL- <br /> CONTRACTOR LICENSE M yam ICC CERTIFICATION X ^per <br /> 41518 Slo a-I q _ U <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 professional engineer havin education and experience with under ound storage tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE <u PHONE Nr. <br /> CERTIFIF:R'S NAME(print) X15 CERTIFIER'S TIT <br /> ` ue. <br /> �TtN V, we tTNKEIIJ ltpL a 6�7� <br /> NAME OF CERTIFIER'S EMPLOYER(DHA) 4e8 CERTIFIERS RELATIONSHIP TO TANK OWNER 4", <br /> r\� `''� [IL TANK OWNER [32.TANK OPERATOR <br /> t J rLt7f'k S UAS �! ,,.CONTRACTOR [14.PROPERTY OWNER <br /> ❑ 5,OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(12/2007) <br />