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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION I MODIFICATION <br /> (One form per project.) <br /> 1. FACILITY INFORMATION <br /> FACILITY ID!!(Agency Use Only) <br /> :IIELEEIE77-, <br /> . <br /> BUSINESS NAME(S--m FACILM NAME o,DBA-Doing Business As) <br /> 3 <br /> BUSINESS SITE ADDRE S 103 CITY 104 <br /> V- C <br /> II. INSTALLATION/MODIFICATION PRO CT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aQLlly) 493• WORK AUTHORIZED UNDER PERMIT 4836 <br /> ❑ 1 TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 2.PIPING INSTALLATION OR REPLACEMENT i" f <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 /> l S Q Cf VLU Q l�(Cvl uj�. ak <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 482. <br /> CONTRACTOR LICENSE N 4826 ICC CERTIFICATION k 492,. <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 storage 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: 496 <br /> �(R�T IJ (,L}F l i f�l.-( A� t, t_ -� (�`�cC4e•1� <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S LATIONSHIP TO TANK OWNER 489 <br /> ❑ 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> J l( ] 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-IR <br /> Rev.(12/2007) <br />