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A05ECOVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM JUN 0 1 2009 <br /> UNDERGROUND STORAGE TANK <br /> E: <br /> CERTIFICATION OF INSTALLATION/MODIFI HENT HEALTH <br /> 1Tproject.) <br /> 1. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> t. <br /> BUSINESS NAME(Sarre as FACIL Y NAME or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> ( +(& St. 'rt�cie � ' q 5 3 f1 <br /> II. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that al2pl ) 483& WORK AUTHORIZED UNDER PERMIT 4a3b. <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> S.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: <br /> 493c <br /> o <br /> 6v% <br /> -Ri SU <br /> y)(k,L"L 46"6 csv-zc - ubc- 3I4-- <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482a <br /> b r,L &LLCe `C e. I K <br /> CONTRACTOR LICENSE# 48zb. ICC CERTIFICATION# Qazc. <br /> 1!�*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 /> by a registered professional engineer having education and ex erience with underground stora a tank system installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 484 PHONE 487. <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: Qae. <br /> XIF.T <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 4888, <br /> RELATIONSHIP TO TANK OWNER 489. <br /> _ ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> S-evU dor. I,3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> w�Vv ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1R <br /> Rev.(12/2007) <br />