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RE('% <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> CERTIFICATION OF INSTALLATION /MODIFft� ENTAL HCHAL.. <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Onl)) <br /> BUSINESS NAME(Same as FACILITY NAME m DBA-Do,.g Busmen As) 3 <br /> �P/^�nt`L C, -it-zja, <br /> BUSINESS SITE ADDRESS l03 CITY Toa <br /> 3 f� �• CA.�t�oeH r ra �• stc�l[�-ort. <br /> H. INSTALLATION/MODIFICATION PROJECT DESCRIPTION <br /> TYPE OF PROJECT(Check all that aDDly) 483.. WORK AUTHORIZED UNDER PERMIT 483b <br /> ❑ 1.TANK INSTALLATION OR REPLACEMENT <br /> [-12.PIPING INSTALLATION OR REPLACEMENT (Number or Date): <br /> ❑ 3.SUMP INSTALLATION OR REPLACEMENT SAN .qu�auN S 000796 n <br /> ❑ 4.UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT <br /> 5.OTHER <br /> DESCRIPTION OF WORK BEING CERTIFIED: ae37 <br /> Remove existing straight droptubes and replace with flapper style droptubes and remove ball-floats from all USTs. <br /> III. CONTRACTOR INFORMATION <br /> NAME OF CONTRACTOR WHO PERFORMED INSTALLATION MODIFICATION 48za <br /> Gettler-Ryan Inc <br /> CONTRACTOR LICENSE# 4 <br /> 82b ICC CERTIFICATION# aez <br /> 220793 16806�5l 7 <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 tank system installations. <br /> SIGNATURE OF TANK OWN4R ORO R'S AGENT DATE // 481 PHONE aaz <br /> ( 916 ) 851-1830 <br /> CER IER'S NAME(print) 485 CERTIFIER'S TITLE: 486 <br /> Michael Carruth Project Manager <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) 488 CERTIFIER'S RELATIONSHIP TO TANK OWNER 489 <br /> Gettler-Ryan Inc ❑ 1 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 />