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9255517888 Line 1 14:59:14 06-13-2011 3/3 <br /> 1'1L•L 1 1�V V1�tf1R V Vl\OVLILH 1 GL.['Vril\ - , <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFICATION <br /> (One form per project.) <br /> L;-PAC II:ITX'IN, RMATION <br /> FACILITY ID#(Agency Use Only) fi <br /> BUSINESS NAME(Sane as FACILITY NAME or DHA-Doing Business As) 3. <br /> BUSINESS SITE ADDRESS I03. CITY I04. <br /> & <br /> IL—INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that apply) 493a WORK AUTHORIZED UNDER PERMIT 483b. <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 /> OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: 493c <br /> 140,ui vQ, 4x iock <br /> 'Ces�e� wn d �� keyed 4 4- <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR` WHOPERFORMED INSTALLATION!MODIFICATION 482a <br /> t� Wou <br /> CONTRACTOR LICENSE# 4111. ICC CERTIFICATION# 482c. <br /> 22o'I <br /> COSIV4 33- U-Ir <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 re istered professional engineer having education and experience with underground storage tank s stem installations. <br /> SIGNATURE OF TANK OWNER OR OWNER'S AGENT DATE 454. PHONE 487- <br /> �o q t1 ( � <br /> CERTIFIER'S NAME(print) 485 CERTIFIER'S TITLE: 486. <br /> an <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489. <br /> ❑ II TANK OWNER ❑ 2.TANK OPERATOR <br /> �� '[ln L'f 3.CONTRACTOR ❑ 4.PROPERTY OWNER <br /> '+'T L ❑ S.OTHER AUTHORIZED AGENT OF TANK OWNER <br /> UPCF UST-C-1/2 Rev.(12/2007) <br />