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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project) <br /> 1. FACILITY INFORMATION <br /> FACILITY IDN(Agency Use Only) <br /> t. <br /> BUSINESS NAME(Sone u FACB.rtY NAME or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADDREPS 103. CITY 104 <br /> II. INSTALLATION/MODIFICATION PROJE—TiDESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 481, WORK AUTHORIZED UNDER PERMIT 493b <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 I 1 l <br /> DESCRIPTION OF WORK BEING CERTIFIED: 4937 <br /> III. CONTRACTOR INFORMATION <br /> NAME OF C/ONTRACCTTO,RyWHO <br /> PERFORMED INSTALLATION/MODIFICATION 492& <br /> Sit LI�� Vl(} ter Y1 51117 V <br /> CONTRACTOR LICENSE N 492b, ICC CERTIFICATION N 492a <br /> s -,) �, - � r <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 tanks stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 494 PHONE 497. <br /> l �) . r (4 - J(a ( qa) �i3 -(cc f, <br /> CERTIFIER'S NAME(print) I 48) CERTIFIER'S TITLE: 496. <br /> LO-( ,c L)4icty, <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 466 CERTIFIERS RELATIONSHIP TO TANK OWNER 499 <br /> ❑ I.TANK OWNER ❑ 2.TANK OPERATOR <br /> 't 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> c Q.Y L'' `•1 S��.I/LlS, l ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-112 Rev.(1112007) <br />