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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION/MODIFICATION <br /> (One form per project.) <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(S—u FACarrr NAME.,DBA-Do..a Bwif A5) <br /> J Ll` � 7 <br /> BUSINESS SITE AD DRE C+ tol. CITY w <br /> II. 1NSTALLATI6/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aooly) 483. WORK AUTHORIZED UNDER PERMIT483b <br /> [:J1.TANK INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ <br /> 2.PIPING INSTALLATION OR REPLACEMENT <br /> C) 3.SUMP INSTALLATION OR REPLACEMENT <br /> 5.OTHER4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENTC666 3 <br /> S <br /> DESCRIPTION OF WORK BEING CERTIFIED: l <br /> 487c <br /> (4 f ✓Ll-e od t4- 61 it Lu t� Co(d 1 zu <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION/MODIFICATION 492. <br /> t)-t2V'l)t,�s•�. S�C�'f( � S �-C 1.L(S � <br /> CONTRACTOR LICENSE N 492b. ICC CERTIFICATION k 482, <br /> IV.CERTIFICATION <br /> 1 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 /> �et��ltit -� 3h <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 496. <br /> kRRT-(tJ V. LQ lTt{k-llltil <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 499 <br /> c ❑ L TANK OWNER ❑ 2.TANK OPERATOR <br /> 3.CONTRACTOR ❑ 4 PROPERTY OWNER <br /> ❑ 5.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 <br /> Rev.(12/2007) <br />