Laserfiche WebLink
FROM ;KAISER COMMERCIAL PETROLE FAX NO. :12098871904 'eb. 09 2009 03:13PM P2 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />CERTIFICATION OF INSTALLATION / MODIFICATION <br />(One form per project.) <br />L FACILITY INFORMA77ON <br />FACILITY ID # (Agency Ux 0*) <br />1. <br />BUSINESS NAME (NAnle a FAC MM NA?& orDSA—Dm=BmzwsA3) 3 <br />BUSWMC. SIT ADDRESS 103 <br />C= LOO. <br />IL 1lNSTALLATiON / MODM TION PROJECT DESCRIP'iTON <br />TYPE OF TyROJF.CT (Check gLtb_a ,0� "Q' <br />WORK AUTIiORIVFD CINDER PERMIT <br />Q 1. TANK INSTALLATION OR REPLACEMENT <br />,FO'2. PIPING INS'CALLATION OR REPLACEMENT <br />(Nmnbcr or Dom} <br />3. SUMP TNSTALLATIONORREPLACEMINT <br />4. UNDER DISPENSM CONTAINMENT INSTALLATION OR REPLACEMENT <br />❑ 5.OTHER <br />DESCR1Y110N OF WORK BF,ING CERTIFIED, <br />1 lt�� , I, (<,7,c1 � � Ft I S/0 i <br />-�; <br />ui� ltf /04A� /I r / KE - <br />Id CONTRACTOR INFORMATION( <br />NAMl; FCONTRACTORWHOP1=12FRFURMYL)INSTALLATIONII�IF1 TI � <br />�J <br />CONTRACTOR LICENSE -9 <br />FCC CERTIFICATION 9 <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 undergaround storage tank, any primary piping and any secondary containment was installed according to applicable <br />voluntary comensus standards and any manufacturer's written installation instructions- <br />• All work listed in the manufacturer's installation checklist has been completed. <br />• The installation h inspected and approved by the local agcncy, or if required by the local agency, inspected and certified <br />b art s fessio—r en ineer having cdut on and ence with and and sto c tank stem im•tal latlons_ <br />SIGNATUREOWNI?Ii OR OWNER'S AGENT DATE ONE <br />CERTIF 6 (print) 495CERTIFIER'S <br />TITLE: <br />N OF CFR IER' ME LOYER (DBA) "`� <br />CERT IFIER'S RELATIONSTVP TO TANK OWNF,R 4n <br />[] 1. TANK OWNER [12- TANK OPERATOR <br />-M'3 CONTRACTOR ❑ 4_ PROPERTY OWNER <br />❑ S. OTHER AUTHORIZED AGENT OF TANK OWNER <br />UPCF UST -C -1/2 Rev. (12/20" <br />