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04/17/2009 13:03 FAX 9163712540 BZMAINr Z002 <br /> 0 <br /> U IFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICA' ION OF INSTALLATION /MODIFICATION(One fa m Per proles) <br /> I. FACILITY INFORMATION <br /> I. <br /> FACILITY m#(Agency Use Unly) — <br /> HU$INESS AME(a .FACa_,ry NAME.,DBA- amines M) <br /> IM, <br /> BUSINESS SITE ADDRESS tm. CITY <br /> as S. S� <br /> IL INSTALLATION/MODIFICATION PROJECT DESCRIPTION 40b,TYPE OF PROJECT(Check all that aaol)) 4�` WORK AUTHORIZED UNDER PERMIT <br /> ❑ ].TANK iNSI'AWATION OR RF.PLACEM674T <br /> (Number or Daft): <br /> ❑ 2,PIPING INSTALLATION OR REPLACEMkN F <br /> ❑ 3.SUMPINSTALLATIONORREPLACEME <br /> 4.UNDER DISPENSER CONTAINMENT IN$TALIATION OR REPLACEMENT <br /> 5.OTHER n <br /> pnDrPS(Cy�� �'C(IO�N/'IOFRK BEING CRRTIF P /���y7 ^ �[1^ !• /� 1 I/ <br /> C.(l..Q / � U ✓•.Ll.�i "l. Jc.L'�1 ')C 1 t (( , ( , ,(- �1M1J�l.i(_, <br /> �I <br /> III. CONTRACTOR INFORMATION <br /> 4U1 <br /> NAME OFA NTRACTOR WIiO ,DIN TALLATION I MODIFlCATION <br /> P) 9 <br /> 4nb. 4F1e <br /> CONTRACTORLII EN E# ICC CERTIFICATION <br /> W— 7 <br /> IV.CERTIFICATION <br /> I certify that the information Provide herein is trae,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). applicable <br /> • The underground storage tank, a4y primary piping, and any secondary'containment was installed according [o <br /> voluntary consensus standards and any manufacturer's written installation itistructions. <br /> a All work listed in the maaufacturerhs 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 /> • a re istered to ion en weer havin education and ex acne with under ound stor c tank stem installations. +� <br /> +� PnoNe <br /> SIGNA' E Of TAN WNER OR OWNER IS AGENT / <br /> t— i .nn <br /> nes TIFIEft'S TITI <br /> CERTIFI• 'SNAME n1) <br /> ar .Fv. <br /> NAMEOERl'1FIER:IS EMPLO,SC�Tt�(D )I CF-RTIr1ER'S RELATIONS TO TANK OWNER <br /> \-N(� AVi1 ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> ��'S\t �� U 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> ❑ 5.O'1'iIP.R AUTHORIZED AGENT OF TANK OWNER <br /> R".(12t2067) <br /> UPCF UST-C•IR <br /> I <br />