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Jun 17 08 09:46a Gesspecs Inc 2098324543 p.2 <br /> 4 v _ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project) <br /> 4 I. FACILITY INFORMATION <br /> FACILITY ID (Agency Use <br /> BUSLNESSNAME(Sam=F=11[Vh'ameo DSA—D ng BusJwnAs1 3' <br /> C-ee t �tS �Al2 vj�&v� O `M�fL1 <br /> BUSINESS SITE ADDRESS 1-5 1 CITY Iw <br /> 2\\s �\A km, C Gs33-1 <br /> 11. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Checkafl that aaaly) ' WORK AUTHORIZED UNDER PERWT ti <br /> g 1.TANK INSTALLATION OR REPLACEMENT (Number m Date): <br /> ® 2 PIPING INSTALLATION OR REPLACEMENT <br /> 91 3,SUMP INSTALLATION OR REPLACEMENT <br /> •, <br /> 04,UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRLPTION OF WORK BEING CERTIFIED: <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION <br /> CONTRACTOR LICENSE 4 I `h �r M ICC CERTIFICATION M <s:... <br /> 'r CJ TV. 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 in lation has b n inspected and approved by the local agency, or if required by the local agency,inspected and certified <br /> b s red roessl n ' eer havingeducation and a erience with underground storage tanks stem installations. <br /> SIGMA O K O ER R O NER'S AGENT DATE ^� PHONE ar. <br /> (o- llo- <br /> CER ER' N P\. ass. CERTIMR'S TITLE: <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 988CERTIFIER'S RELATIONSHIP TO TANK OWNER 49_ <br /> _ 1.TANK OWNER I`3 2.TANK OPERATOR <br /> C��G L9�C�/ �(� ❑ 3.CONTRACTOR 19 4.PROPERTY OWNER <br /> J W ❑ <br /> 5.OTHER AUF140RIZED AGENT OP TANK OWNER <br /> UPCF UST-C Rev.(12/2107)-12 w .aaidoesarg <br />